Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Waiver Or Fees And Court Costs Form. This is a Oregon form and can be use in Tax Court Statewide.
Loading PDF...
Tags: Application For Waiver Or Fees And Court Costs, Oregon Statewide, Tax Court
IN THE OREGON TAX COURT
MAGISTRATE DIVISION
___________________________________,
___________________________________,
Plaintiff(s),
v.
Note: Identify the defendant(s) named in your complaint.
________________ COUNTY ASSESSOR
DEPARTMENT OF REVENUE,
State of Oregon,
Defendant.
)
)
) TC-MD___________________
)
)
)
)
)
)
)
)
)
) APPLICATION FOR WAIVER OF FEES
) AND COURT COSTS
I/We request waiver of fees in this case because I/we cannot pay all or part of the fees.
(The fees, including surcharge, are $75.) The following information is complete and accurate
to the best of my/our knowledge. I/We understand that I/we may be required to provide
documentation verifying this information. I/We understand that failure to do so could result in
my/our request being denied.
You must complete the Affidavit of Income, Assets, and Expenses In Suppor t of
Application for Waiver of Fees and Cour t Costs with this application. The affidavit is
designed to prove to the court that you do not have sufficient financial resources to pay the fees.
I/We declare that (check one of the boxes below):
(1) I/We receive public benefits under one of the following programs (you must
pr ovide pr oof of cur r ent eligibility for any pr ogr am checked below).
(a)
(b)
(c)
(d)
Temporary Assistance to Needy Families (TANF).
Food Stamps-Supplemental Nutrition Assistance Program (SNAP).
Supplemental Security Income (SSI).
Oregon Health Plan (OHP) package:
1. OHP Plus;
2. OHP Standard; or
3. OHP with limited drug.
If you checked item (1) above, attach the necessary documentation and sign this application.
APPLICATION FOR WAIVER
OF FEES AND COURT COSTS
Rev. 01/11
1 of 2
American LegalNet, Inc.
www.FormsWorkFlow.com
(2) Even though I/we do NOT receive assistance from any of the above programs, I/we
cannot pay the fees and court costs. Based on the attached affidavit, I/we cannot pay the fees and
court costs (complete and sign the attached affidavit).
_______________________________
(signature)
_______________________________
(date)
_______________________________
(print or type name)
_______________________________
(signature)
_______________________________
(date)
_______________________________
(print or type name)
APPLICATION FOR WAIVER
OF FEES AND COURT COSTS
Rev. 01/11
2 of 2
American LegalNet, Inc.
www.FormsWorkFlow.com
IN THE OREGON TAX COURT
MAGISTRATE DIVISION
___________________________________,
___________________________________,
Plaintiff(s),
v.
Note: Identify the defendant(s) named in your complaint.
________________ COUNTY ASSESSOR
DEPARTMENT OF REVENUE,
State of Oregon,
Defendant.
)
)
)
)
)
)
)
)
)
)
)
)
)
)
TC-MD___________________
AFFIDAVIT OF INCOME, ASSETS,
AND EXPENSES IN SUPPORT OF
APPLICATION FOR WAIVER OF FEES
AND COURT COSTS
________________________________________ ____________________________________
(full name: last, first, middle initial)
(date of birth)
__________________________________ _______ - ________ - _________
(driver license number)
(Social Security number*)
________________________________________ ____________________________________
(full name: last, first, middle initial)
_________________________________
(driver license number)
(date of birth)
_______ - ________ - _________
(Social Security number*)
___________________________________________________
________________________
(street address)
(telephone number)
* 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 the failure to provide it. It may be used to verify my identification, credit, and employment information, and used for
collection purposes for court-imposed monetary obligation.
(1) EMPLOYMENT AND OTHER INCOME
Present employer, if currently employed
Previous employer, if not currently employed. How long
since last employment?______________________________
Employer __________________________________ How long? _________ Occupation (title) _______________
Address _____________________________________________ Work phone _____________________________
Hourly wage _________ Hours per week _________ Monthly pay: gross ______ or net (after taxes) _______
Previous employer, if not currently employed.
How long since last employment?_______________
Employer __________________________________ How long? _________ Occupation (title) ________________
Address _____________________________________________ Work phone______________________________
Hourly wage _________ Hours per week __________ Monthly pay: gross ______ or net (after taxes)_______
AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES
IN SUPPORT OF APPLICATION FOR WAIVER OF
FEES AND COURT COSTS
Rev. 01/11
1 of 3
American LegalNet, Inc.
www.FormsWorkFlow.com
Other income for you and your spouse, dependents or household members; for example, Social Security,
etc.:
Source of Income (describe)
________________________________
________________________________
________________________________
________________________________
Amount
______________
______________
______________
______________
How long received
__________________
__________________
__________________
__________________
How often received
_________________
_________________
_________________
_________________
Other household members who help pay for your living expenses:
Relationship
________________________________
________________________________
________________________________
________________________________
Amount
______________
______________
______________
______________
Payment for what? (describe)
_______________________________________
_______________________________________
_______________________________________
_______________________________________
(2) MONEY ON HAND/IN BANK
Cash _______________________
Checking Account No.___________ Bank/Credit Union_________________________ Balance ______________
Savings Account No.___________ Bank/Credit Union_________________________ Balance ______________
Other Account No.___________
Bank/Credit Union_________________________ Balance ______________
(3) MOTOR VEHICLES Make and year
__________________________________
__________________________________
__________________________________
Value
___________
___________
___________
Amount owing
____________
____________
____________
Vehicle payments made to
_____________________________
_____________________________
_____________________________
(4) REAL ESTATE Address and city
__________________________________
__________________________________
__________________________________
Value
___________
___________
___________
Amount owing
____________
____________
____________
House payments made to
_____________________________
_____________________________
_____________________________
(5) ALL OTHER PROPERTY OR ASSETS (All other property or assets exceeding $200 in value; for example,
furniture, stocks, bonds, boats, R.V.s, trailers, campers, guns, and jewelry)
Description
Value
Description
Value
__________________________________ _________ __________________________________ __________
__________________________________ _________ __________________________________ __________
(6) MONEY OWED TO YOU BY OTHERS (for example, tax refund, settlement, judgment, or trust funds)
Name of debtor
Amount owed
Date expected
________________________________________________ _______________________ _________________
________________________________________________ _______________________ _________________
________________________________________________ _______________________ _________________
(7) NUMBER OF DEPENDENTS IN HOUSEHOLD: ______________
AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES
IN SUPPORT OF APPLICATION FOR WAIVER OF
FEES AND COURT COSTS
Rev. 01/11
2 of 3
American LegalNet, Inc.
www.FormsWorkFlow.com
(8) LIVING EXPENSES
Rent/Mortgage
______________
Utilities
______________
Food
______________
Vehicle payment(s)
______________
Medical Expenses
______________
Child support payment(s) ______________
Credit card payment(s)
______________
Department stores
______________
Other
______________
Other
______________
TOTAL
______________
(9) OTHER INFORMATION THE COURT SHOULD KNOW
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
IMPORTANT: You must sign this affidavit in the presence of a notary public.
I/We understand that the information I/we have provided above may be verified. I/we, the undersigned,
swear or affirm that the information I/we have provided is true and correct to the best of my/our knowledge. I/We
understand that if I/we do not tell the truth, I/we can be charged with perjury or false swearing and, if convicted,
I/we can be imprisoned, fined, or both.
_______________________
(date)
_______________________
(date)
_________________________________________
(signature)
_________________________________________
(signature)
State of Oregon
)
) ss.
)
County of ____________
SUBSCRIBED AND SWORN before me this ______ day of _________________, ___________.
____________________________________
Notary Public for Oregon
My Commission Expires: _______________
ACCESS TO THIS DOC
PROTECT THE PERSONAL PRIVACY INTEREST OF PARTIES.
AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES
IN SUPPORT OF APPLICATION FOR WAIVER OF
FEES AND COURT COSTS
Rev. 01/11
3 of 3
American LegalNet, Inc.
www.FormsWorkFlow.com
