Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 1 of 5 Case No: IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF Case No. Plaintiff /Petitioner v. Application & Declaration for Deferral or Waiver of Fees for: Plaintiff/Petitioner Defendant /Re spondent 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 * Motion Fee Arbitration Fee Trial Fee Other (describe) : *If you are requesting deferral or waiver 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 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. American LegalNet, Inc. www.FormsWorkFlow.com Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 2 of 5 Case No: Declaration 1. PERSONAL Full Name of Applicant: First Name Middle Name Last Name Residence Address: Street Address City State Zip Mailing Address (if different): Address City State Zip Phone: Date of Birth (month/day/year) Marital Status: *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 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 American LegalNet, Inc. www.FormsWorkFlow.com Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 3 of 5 Case No: Source of Income (describe) Amount How long received? How often? $ $ $ $ Additional Page Attached 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 $ Food $ Trash $ Utilities Electric $ Gas $ Water $ Sewer $ P hone $ Cell $ Cable $ Internet $ Transportation Vehicle payment s $ Insurance $ /month Gas $ Bus $ Parking $ Other Credit cards $ Student loans $ Court fines $ Medical $ Child support $ 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 Year Purchase Price Value Amount Owed Payments Made to: $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 4 of 5 Case No: $ $ $ 8. ALL OTHER PROPERTY OR ASSETS (such as: ATVs, RVs, boats, guns, jewelry, livestock, etc.): Description Value Description Value $ $ $ $ $ $ 9. LIQUIDATION OF ASSETS If you are unable to sell or liquidate your assets, explain why: 10. MONEY OWED TO YOU BY OTHERS (tax refunds, judgments, trust funds, settlements, etc.): Name of Debtor Owing You Money Amount Owed Date Expected $ $ 11. ARE YOU SEEKING TEMPORARY CHILD AND/OR SPOUSAL SUPPORT? No Yes (How much? $ 12. OTHER INFORMATION YOU WANT COURT TO CONSIDER Do you have a lawyer (or do you plan to) to represent you in this case? Yes No Have you paid your lawyer money? No Yes (How much? $ ) Do you have a contingency fee agreement with your lawyer? No Yes Certificate of Document Preparation. Check all that apply: I chose this form for myself and completed it without paid help. A legal help organization helped me choose or complete this form, but I did not pay money to anyone. I paid (or will pay) for help choosing, completing, or reviewing this form. TurboCourt selected and completed this form and I did not pay anyone to review the completed form I hereby declare that the above statements are true to the best of my knowledge and belief, and that I understand they are made for use as evidence in court and I am subject to penalty for perjury. Date Signature of Applicant ( Plaintiff/Petitioner Defendant/Respondent) Name of Applicant (printed or typed) American LegalNet, Inc. www.FormsWorkFlow.com Fee Deferral or Waiver Application and Declaration (eForm: 11/9/12) Page 5 of 5 Case No: INSTRUCTIONS FOR FEE DEFERRAL OR WAIVER APPLICATION & DECLARATION Fees and costs are required in any civil case, including dissolutions (divorce), small claims, evictions (FED Forcible Entry and Detainer), and arbitration. A list of fees is available at www.courts.oregon.gov or from the court clerk. The court accepts cash, credit and debit cards, and money orders or checks made out to the State of Oregon. If you cannot afford to pay the amount required, you may ask the court to defer or waive those fees and costs. If the court defers the fees and costs you do not need to pay them at the time of filing. You still have to pay according to the schedule set up by the court. If you want to apply for a deferral or waiver of fees, complete the following forms: The case heading must be the same as on the papers you filed or received APPLICATION & DECLARATION FOR DEFERRAL OR WAIVER OF FEES. Fill in the case heading and mark whether you are the Plaintiff/Petitioner or Defendant/Respondent. You must completely fill out the Declaration. Do not leave any sections blank. Date, sign, and print your name