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Affidavit In Support Of Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs Form. This is a Oregon form and can be use in Marion Local County.
Tags: Affidavit In Support Of Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs, Oregon Local County, Marion
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