Judgment Fee Deferral or Waiver (eForm: 11/9/12) Page 1 of 1 Case #: IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF Case No: Plaintiff /Petitioner LIMITED SUPPLEMENTAL v. JUDGMENT AND MONEY AWARD RE: DEFERRED FEES Defenda nt /Respondent The court finds that the Judgment Debtor has not paid the noted fees. The court awards judgment for the State of Oregon and against the judgment debtor for the unpaid amount of: Filing Fees S Service Fee Motion Fee Arbitration Fee Trial Fee Other (describe) : MONEY AWARD 1. Judgment Creditor: State of Oregon (address of this court): a. Judgment Creditolawyer (name, address, phone number) 2. Judgment Debtor Name Address Year of Birth SSN (last 4 digits) or Full Tax ID Driver License # (last 4) & State Lawyer ( name and bar #) 3. The total amount awarded by this judgment is $ . This amount does not include interest, attorney fees, or prevailing party fees. No interest will accrue post-judgment. Additional collection costs may be added without further notice to judgment debtor under ORS 1.202. Date Circuit Court Judge or designee Print Name American LegalNet, Inc. www.FormsWorkFlow.com