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___________________ ) ) ) ) ) ) ) ) ) ) PLAINTIFF’S(S’) APPLICATION FOR ) WAIVER OF FILING FEE I/We apply for waiver of the $25 filing fee. I/We declare that (check item (1) or (2)):  (1) I/We receive public benefits under one of the following programs (you must provide proof of current eligibility for any program checked below).  (a) Temporary Assistance to Needy Families (TANF).  (b) Emergency Assistance (EA).  (c) Food stamps. If you checked item (1) above, attach the necessary documentation, skip item (2) below, and sign this application.  (2) Based on the attached affidavit, I/we cannot pay the filing fee (complete and sign the attached affidavit). _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) APPLICATION FOR WAIVER OF FILING FEE Rev. 05-08 1 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 FILING FEE ________________________________________ ____________________________________ (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) _______  Spouse’s 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)_______ Rev. 05-08 Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com  Other income for you and your spouse, dependents or household members; for example, Social Security, unemployment, retirement, public assistance, child or spousal support, workers’ compensation, disability, 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, trust funds) Name of debtor Amount owed Date expected ________________________________________________ _______________________ _________________ ________________________________________________ _______________________ _________________ ________________________________________________ _______________________ _________________ (7) NUMBER OF DEPENDENTS IN HOUSEHOLD: ______________ Rev. 05-08 Page 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) SUBSCRIBED AND SWORN before me this ______ day of _________________, ___________. ____________________________________ Notary Public for Oregon My Commission Expires: _______________ ACCESS TO THIS DOCUMENT IS RESTRICTED PURSUANT TO THE COURT’S POLICY TO PROTECT THE PERSONAL PRIVACY INTEREST OF PARTIES. Rev. 05-08 Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com