IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT In the Matter of: ) ) ___________________________________, ) Petitioner, ) and ) ) ___________________________________, ) Respondent. ) AFFIDAVIT IN SUPPORT OF ‘ DEFERRAL ‘ WAIVER OF FILING FEES Case No. ____________________ I swear/affirm that I am the ‘ Petitioner ‘ Respondent, that I am unable to pay necessary fees, that I support ______ people, and that my assets, monthly income, and expenses are as follows: 1. Name, age and relationship of people I am supporting: __________________________________________________________________ __________________________________________________________________ 2. Date of Birth: _______________________________ Oregon Driver’s License Number: _______________ 3. Employer Names: ___________________________________________________ Employer Address: __________________________________________________ __________________________________________________ Length of Employment: _______________________ Monthly Pay (Net): ___________________________ 4. All other income (include income from members of your household available to you or used to off-set your expenses): Monthly Total: ______________________ Sources: __________________________________________________________ AFFIDAVIT- Page 1 of 2 FC(7/12/05) (Domestic Relations) American LegalNet, Inc. www.USCourtForms.com 5. All other assets: What it is worth What you owe Real Property: _________ ________ Motor Vehicles: _________ ________ Other Property (guns, jewelry, stocks, bonds, etc.): ____________________________________________________________ ____________________________________________________________ 6. Bank Accounts and Cash: ____________________________________________ 7. Money owed to me or my spouse by others: ______________________________ __________________________________________________________________ 8. Expenses, Monthly: Housing Car Pmts Loan Pmts $ _________ owed to ______________________________ $ _________ owed to ______________________________ $ _________ owed to ______________________________ $ _________ owed to ______________________________ $ _________ owed to ______________________________ Other Living Expenses: $ _________ for __________________________________ $ _________ for __________________________________ $ _________ for __________________________________ $ _________ for __________________________________ DATED this _____ day of _________________________, _______. ____________________________________ Signature ____________________________________ Printed/Typed Name ____________________________________ Address ____________________________________ City/State/Zip ____________________________________ Telephone Number Subscribed and sworn to before me this _____ day of ____________________, _____. ____________________________________ Deputy Court Administrator/Notary Public My Commission Expires: ______________ AFFIDAVIT- Page 2 of 2 FC(7/12/05) (Domestic Relations) American LegalNet, Inc. www.USCourtForms.com