IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF Plaintiff/Petitioner Case No. _____________________ v. Application & Declaration for Deferral or Waiver of Fees for: Plaintiff/Petitioner Defendant/Respondent Defendant/Respondent ACCESS TO THIS DOCUMENT IS RESTRICTED TO PROTECT THE PRIVACY OF PARTIES I am asking for deferral or waiver of fees in this case because I am unable to pay all or part of the fees right now. I understand that I must complete the Declaration for Deferral or Waiver of Fees to prove to the court that I do not have enough money to pay the fees. I understand that if I do not, my request can be denied. 1. I am applying for deferral or waiver of the following fees (check ONE box ONLY): Filing Fees Arbitration Fee Other (describe): Filing Fees + Sheriff's Service Fee* Trial Fee Motion Fee *If you are requesting deferral or waiver of the sheriff's service fee, explain why you cannot find another person to serve the papers. Papers can be served by any competent person who is at least 18 years old, a resident of Oregon (or the state where service is made), and who is not a party to the case or a party's lawyer, employee, officer, or director. 2. If the court defers fees, I understand that: a. The fees are a debt I owe to the State of Oregon, and the court may put me on a payment plan. I agree to pay the fees according to the payment plan. If I fail to do so, the total amount of unpaid fees will be referred for collection. b. The court will enter a judgment against me for the unpaid amount of the fees that are deferred, and the judgment will be enforced regardless of the outcome of the case. c. If the court refers this judgment for collection, administrative and collection costs will automatically be added to the judgment without further notice to me or further action by the court. 3. I understand that if the clerk denies my application, I have the right to ask a judge to review my application. Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 1 of 5 Case No: 1. PERSONAL Full Name of Applicant: Residence Address: Declaration First Name Street Address Address Middle Name City City State State Last Name Zip Zip Mailing Address (if different): Phone: Marital Status: Date of Birth (month/day/year) *SSN: DL/ID: *I am providing my Social Security number voluntarily. I understand that I cannot be forced to provide it or be denied consideration solely for failure to provide it. It may be used to verify my identification, credit and employment information, and for collection of court-imposed monetary obligations. Names and ages of legal dependents living in household: Name Age Name Age _____________________________ ______ ___________________ __________ _____________________________ ______ ___________________ __________ _____________________________ ______ ___________________ __________ _____________________________ ______ ___________________ __________ 2. PUBLIC ASSISTANCE (include the amount you receive PER MONTH, if any) I am now receiving assistance from the following programs (check all that apply): Food Stamps (SNAP-Supplemental Nutrition Assistance Program) - $ Supplemental Security Income (SSI) - $ Temporary Assistance to Needy Families (TANF) - $ Oregon Health Plan (OHP) (If you checked any of the boxes above, you must show proof of the amount that you are receiving.) 3. EMPLOYMENT AND INCOME Your Employment and Income Currently Employed Not Currently Employed How long since last employment? Employer Name (use previous employer if not currently employed) Employer Address Work Phone Occupation (job title) Length of Employment Last Paycheck $ Wages/salary $ per Hours Per Week Monthly Income: Gross (before taxes) $ __ Net (after taxes) $ _ _____ (If you are employed, you must show proof of your income. See Instructions.) Household Members' Employment and Income Name and relationship to you: Currently Employed Not Currently Employed How long since last employment? Employer Name (use previous employer if not currently employed) Employer Address Work Phone Occupation (job title) Length of Employment Last Paycheck $ Wages/salary $ per Hours Per Week Monthly Income: Gross (before taxes) $ Net (after taxes) $ Any other income for you, household members, or dependents in addition to amounts listed in Section 2 (Social Security, food stamps, unemployment, retirement, public assistance, child support, workers' compensation, disability, tribal benefits, etc.): Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 2 of 5 Case No: Source of Income (describe) Amount How long received? How often? ______________________________________ $_________ ____________ __________ ______________________________________ $_________ ____________ __________ ______________________________________ $_________ ____________ __________ ______________________________________ $_________ ____________ __________ Additional Page Attached Other Party's Employment and Income (if known to you) Currently Employed Not Currently Employed How long since last employment? Occupation (job title) Wages/salary $ per Hours Per Week Monthly Income: $ gross (before tax) net (after taxes) 4. MONTHLY LIVING EXPENSES (Total: $ Home Rent/mortgage $ Utilities Electric $ Sewer $ Cable $ ) Food $ Gas $ Phone $ Internet $ Insurance $ Parking $ Student loans $ Child support $ /month Trash $ Water $ Cell $ Transportation Vehicle payments $ Bus $ Other Credit cards $ Medical $ Gas $ Court fines $ Other (describe) (You must show proof of the amount you pay for monthly expenses. See Instructions.) Any other individuals who help pay your living expenses: Relationship Amount Payment for what? 5. MONEY ON HAND / IN BANK Cash $____________ Checking Account # ________________ Bank/Credit Union _____________ Balance $ ________ Savings Account # _________________ Bank/Credit Union _____________ Balance $ ________ Other Account # __________________ Institution ___________________ Balance $ ________ 6. VEHICLES Year, Make, and Model Value Amount Owed Payments made to: ________________________________ $__________ $__________ ________________ ________________________________ $__________ $__________ ________________ 7. REAL ESTATE Address (include city and state) Purchase Purchase Value Amount Payments Year Price Owed Made to: _____________________________ _______ $_______ $_______ $_______ ______ Case No: _ Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 3 of 5 _____