IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _____________________ ______________________________________, Petitioner/Plaintiff, v. ______________________________________, Respondent/Defendant. ) ) ) ) ) ) ) Case No. _________________ Petitioner/Plaintiff Respondent/Defendant APPLICATION FOR WAIVER OR DEFERRAL OF FEES I am asking for waiver or deferral of fees in this case because I am unable to pay all or part of the fees. The following information is complete and accurate to the best of my knowledge. I understand that I may be required to provide documentation verifying this information. I understand that failure to do so could result in my request being denied. 1. I am applying for WAIVER DEFERRAL of the following fees (check all that apply): Arbitration Fee(s) Hearing Fee(s) Sheriff’s Service Fee Other (describe): Filing Fee(s) Motion Fee(s) Trial Fee(s) __________________ Papers may be served by any competent person that is at least 18 years of age; a resident of Oregon or the state where service is made; and is not a party to the case or a party’s attorney, employee, officer, or director. If you are requesting a waiver or deferral of the sheriff’s service fee, please explain why you cannot find another qualified person to serve the papers instead of the sheriff: ________________________________________________________________________________ ________________________________________________________________________________ 2. I declare that (check one of the boxes below): I am receiving assistance from at least one of the following programs: Food Stamps Oregon Health Plan Standard Oregon Health Plan Plus Oregon Health Plan with Limited Drug Supplemental Security Income (SSI) Temporary Assistance to Needy Families (TANF) If you checked the above box, you must be prepared to show proof that you are receiving assistance from the program. You do NOT need to fill out a Declaration for Waiver or Deferral of Fees unless you are enrolled in the Oregon Health Plan’s Qualified Medicare Beneficiary (QMB) program or Citizen Alien-Waived Emergency Assistance (CAWEM) program. If you are enrolled in QMB or CAWEM, you must complete and file the declaration with this application. Even though I am NOT receiving assistance from any of the above programs, I am still unable to pay the fees. If you have checked this box, you must complete and file a Declaration for Waiver or Deferral of Fees with this application. The declaration is designed to prove to the court that you do not have sufficient financial resources to pay the fees. Application for Waiver or Deferral of Fees OJIN Code: AE (Application) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. If the court defers fees, I understand that: a. The fees are an obligation owed by me to the State of Oregon and that the court may place me on a payment schedule. I agree to pay the fees according to the payment schedule. If I fail to pay according to the payment schedule, the total amount of the unpaid fees are due immediately. b. The court may enter a judgment against me for the unpaid amount of the fees that are deferred and the judgment will be enforced without regard to the outcome of the case. c. If the court establishes a payment schedule or refers a judgment for collection, the law allows administrative and collection costs to be automatically added to the judgment without further notice to me or further action by the court. 4. I understand that if the clerk denies my application, I have the right to ask a judge to review my application. __________ __________________________________________ Date Signature of Applicant __________________________________________ Name of Applicant (printed or typed) Application for Waiver or Deferral of Fees OJIN Code: AE (Application) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com