IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _____________________ ______________________________________, ) ) ) ) ) ) ) Petitioner/Plaintiff, v. ______________________________________, Respondent/Defendant. Case No. _________________ Petitioner/Plaintiff Respondent/Defendant DECLARATION FOR DEFERRAL OR WAIVER OF FEES (TO BE COMPLETED BY APPLICANT IN ITS ENTIRETY INCLUDING “N/A” or “0” WHEN APPROPRIATE) ACCESS TO THIS DOCUMENT IS RESTRICTED PURSUANT TO THE COURT’S POLICY TO PROTECT THE PERSONAL PRIVACY INTERESTS OF PARTIES 1. PERSONAL Full Name of Applicant ___________________________________________________________________________ FIRST NAME MIDDLE NAME LAST NAME Residence Address ______________________________________________________________________________ STREET ADDRESS CITY STATE ZIP Mailing Address (if different) _______________________________________________________________________ ADDDRESS CITY STATE ZIP Telephone Number _____________ *SSN ______________ ODL/ID ____________ Marital Status ______________ *I am providing my Social Security number on a voluntary basis. I understand that I cannot be compelled 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 purposes of court imposed monetary obligations. Names and ages of legal dependants living in household: Name Age Name Age _____________________________ _____________________________ ______ ______ ______ ______ _____________________________ _____________________________ 2. 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 ____________ Amount of Last Paycheck $________ Hourly Wage $ _______ Hours Per Week _______ Monthly Income: Gross $_________ Net (after taxes) $________ Household Members’ 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 ____________ Amount of Last Paycheck $________ Hourly Wage $ _______ Hours Per Week _______ Monthly Income: Gross $_________ Net (after taxes) $________ Adverse Party’s 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 ____________ Amount of Last Paycheck $________ Hourly Wage $ _______ Hours Per Week _______ Monthly Income: Gross $_________ Net (after taxes) $________ Declaration for Deferral or Waiver of Fees OJIN Code: STAS (Statement Assets) Page 1 of 3 Updated 8/20/10 American LegalNet, Inc. www.FormsWorkFlow.com Any other income for you, household members, or dependants (for example: Social Security, food stamps, unemployment, retirement, public assistance, child support, workers’ compensation, disability, tribal benefits, etc.): Source of Income (describe) Amount How long received? How often received? ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________ 3. MONTHLY LIVING EXPENSES Rent/Mortgage $_____________ Credit Card Payment $________ Child Support Payment $______ Court Fines $_______________ Cell Phone $________________ Gas $_________ Water $________ Trash $________ Medical $______ Data Plan $____ Electric $_________ Sewer $__________ Phone $__________ Food $___________ Internet $_________ Any other individuals who help pay your living expenses: Relationship Amount ______________________________________ $_________ ______________________________________ $_________ Vehicle Payment $___________ Vehicle Insurance $__________ Transportation Costs $________ Cable TV $_________________ Other _____________ $_______ Payment for what (describe)? _____________________________________ _____________________________________ 4. MONEY ON HAND / IN BANK Cash $____________ Checking Account Number ___________________ Bank/Credit Union ___________________ Balance $ _________ Savings Account Number ____________________ Bank/Credit Union ___________________ Balance $ _________ Other Account Number ______________________ Institution __________________________ Balance $ _________ 5. MOTOR VEHICLES Year, Make, and Model ________________________________ ________________________________ Value $__________ $__________ Amount Owing $__________ $__________ Payments made to: ___________________________ ___________________________ 6. REAL ESTATE Address (include city and state) _____________________________ _____________________________ Year Purchased _______ _______ Purchase Price $_______ $_______ Value $_______ $_______ Amount Owing $_______ $_______ Payments made to: ___________________ ___________________ 7. ALL OTHER PROPERTY OR ASSETS (for example: ATVs, RVs, boats, guns, jewelry, livestock, etc.): Description Value Description Value _____________________________ _____________________________ _____________________________ $______ $______ $______ $______ $______ $______ _____________________________ _____________________________ _____________________________ 8. MONEY OWED TO YOU BY OTHERS (for example: tax refunds, judgments, trust funds, settlements, etc.): Name of Debtor Owing You Money Amount Owed Date Expected _____________________________________________________________ $___________ _____________ _____________________________________________________________ $___________ _____________ Declaration for Deferral or Waiver of Fees OJIN Code: STAS (Statement Assets) Page 2 of 3 Updated 8/20/10 American LegalNet, Inc. www.FormsWorkFlow.com 9. ARE YOU SEEKING AN AWARD OF TEMPORARY CHILD AND/OR SPOUSAL SUPPORT? Yes If so, how much? $_____________ No 10. LIQUIDATION OF ASSETS If you are unable to sell or liquidate your assets, please use this space to explain why: ______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 11. OTHER INFORMATION YOU WANT COURT TO CONSIDER _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you retained an attorney, or do you plan to do so to represent you in this matter? _________________________ If so, who is your attorney? ________________________________________________________________________ Have you paid your attorney money? Yes / No (circle) If so, how much? $__________ Is there a contingency fee agreement? Yes / No (circle) I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT IT IS MADE FOR USE AS EVIDENCE IN COURT AND IS SUBJECT TO PENALTY FOR PERJURY. __________ __________________________________________ Date Signature of Applicant __________________________________________ Name of Applicant (printed or typed) Declaration for Deferral or Waiver of Fees OJIN Code: STAS (Statement Assets) Page 3 of 3 Updated 8/20/10 American LegalNet, Inc. www.FormsWorkFlow.com