IN THE CIRCUIT COURT OF THE STATE OF OREGON THIRD JUDICIAL DISTRICT Probate Department In the Matter of the Guardianship of: __________________________________ Respondent. ) ) County of _______________ ) ) ) ) ) ) ) Case No. AFFIDAVIT IN SUPPORT OF MARION COUNTY INDIGENT GUARDIANSHIP FUND APPLICATION AND/OR MOTION TO WAIVE FEES AND COSTS STATE OF OREGON ss. I hereby swear or affirm that I am or intend to be the Petitioner in the above matter and provide the Court the following information: 1. The Respondent has no or insufficient financial resources which could be utilized to pay for the expense of establishing a guardianship for the Respondent. 2. If I am related to the Respondent by blood or marriage, I have no or insufficient financial resources which could be utilized to pay for the expense of establishing a guardianship for the Respondent. 3. I have reviewed and am familiar with the eligibility requirements and the compensation guidelines for the Marion County Indigent Guardianship Fund. SECTION A - TO BE COMPLETED BY ALL APPLICANTS 1. The source and amount of Respondent’s income is: ________________________________________ ____________________________________________________________________________________ 2. Respondent’s assets are (list type and value and include bank accounts, funds held by others, real estate, autos, stocks, etc.): ______________________________________________________________ ____________________________________________________________________________________ 3. The nature and amount of Respondent’s expenses are: _____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4. Describe the Respondent’s current medical, physical and/or mental condition which necessitates the appointment of a Guardian: _____________________________________________________________ ____________________________________________________________________________________ 5. Describe what other efforts have been made to obtain guardianship or other medical decision making authority for the Respondent: ____________________________________________________________ ____________________________________________________________________________________ 6. Describe what other efforts have been made to get funds to pay for the costs of obtaining a guardianship for the Respondent: ________________________________________________________ ____________________________________________________________________________________ 7. Is the Respondent a client of Senior Services, Mental Health, Disability Services, or other State, County, or local agency? ” Yes ” No If yes, which agency? ________________________________ AFFIDAVIT IN SUPPORT OF MARION COUNTY INDIGENT GUARDIANSHIP FUND APPLICATION AND/OR MOT ION TO W AIV E FEE AN D C OS TS - Page 1 of 2 FC (10/20/04) American LegalNet, Inc. www.USCourtForms.com 8. Does the Respondent currently receive Medicaid or SSI benefits? ” Yes ” No 9. Is the Respondent currently employed? ” Yes ” No SECTION B - TO BE COMPLETED BY APPLICANTS RELATED TO THE RESPONDENT BY BLOOD OR MARRIAGE 1. Your Full Name: _______________________________________Phone:_______________________ 2. Address, City, State, Zip: _____________________________________________________________ 3. Social Security No. _____________________________________Married: ” Yes ” No 4. Your relation to the Respondent is: _____________________________________________________ 5. Name and address of your spouse or nearest relative:________________________________________ ____________________________________________________________________________________ 6. Name, address and age of your dependent children and relationship of any other dependents you are supporting: ___________________________________________________________________________ ____________________________________________________________________________________ 7. Name and address of current employer: __________________________________________________ ________________________________________________________Monthly net pay: ______________ 8. Name and address of spouse’s current employer: __________________________________________ ________________________________________________________Monthly net pay: ______________ 9. List all other sources of income besides employment pay for yourself and your spouse: ____________ ____________________________________________________________________________________ 10. List balance and name of bank for any bank accounts owned by you or your spouse: _____________ ____________________________________________________________________________________ 11. List all other property or assets owned by you or your spouse and their value (example - stocks, bonds, jewelry, furniture, etc): ____________________________________________________________ ____________________________________________________________________________________ 12. List the amount and name of debtor for money owed to you or your spouse by others: ____________ ____________________________________________________________________________________ 13. List the nature and amount of your expenses: ____________________________________________ ____________________________________________________________________________________ NOTE TO ALL APPLICANTS: Attach a copy of the letter or form from the referring agency confirming payment authorization. The above information is true and I ask the Court to use this information to determine whether this case can be approved for payment from the Marion County Indigent Guardianship Fund and/or waiver of court fees and costs. _____________________________________ Signature of Applicant SUBSCRIBED AND SWORN TO before me this ________ day of _________________, 20______. Submitted by: ______________________________________ Name Bar No. (if any) _______________________________________ Address _______________________________________ City, State, Zip ______________________________________ Clerk/Notary/Judge My Commission Expires: _________________ ______________________________________ Telephone ______________________________________ E-mail Fax AFFIDAVIT IN SUPPORT OF MARION COUNTY INDIGENT GUARDIANSHIP FUND APPLICATION AND/OR MOT ION TO W AIV E FEE AN D C OS TS - Page 2 of 2 FC (10/20/04) American LegalNet, Inc. www.USCourtForms.com