IN THE OREGON TAX COURT REGULAR DIVISION ___________________________________, ___________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) TC No. ______ APPLICATION FOR WAIVER OR DEFERRAL OF FEES AND COURT COSTS I/We request deferral or waiver of fees in this case because I/We cannot pay all or part of the fees. 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 or Defer r al 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. (2) Even though I/we do NOT receive assistance from any of the above programs, I/we cannot pay the fees. Based on the attached affidavit, I/we cannot pay the fees and court costs (complete and sign the attached affidavit). APPLICATION FOR WAIVER OR DEFERRAL OF FEES AND COURT COSTS Rev. 09-10 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com If the court defers fees and costs, I/we understand that: (a) The fees and costs are an obligation owed by me/us to the State of Oregon and that the court may place me/us on a payment schedule. I/we agree to pay the fees and cost according to the payment schedule. If I/we fail to pay according to the payment schedule, the total amount of unpaid fees and cost becomes immediately due and payable. (b) The court may enter a judgment against me for the unpaid amount of fees and other court costs 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 and/or refers a judgment for collection, the law allows administrative and collection costs automatically to be added to the judgment, without further notice to me or further action by the court. _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) APPLICATION FOR WAIVER OR DEFERRAL OF FEES AND COURT COSTS Rev. 09-10 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com IN THE OREGON TAX COURT REGULAR DIVISION ___________________________________, ___________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) TC No. _____ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION FOR WAIVER OR DEFERRAL 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 OR DEFERRAL OF FEES AND COURT COSTS Rev. 09-10 Page 3 of 5 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 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: ______________ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION FOR WAIVER OR DEFERRAL OF FEES AND COURT COSTS Rev. 09-10 Page 4 of 5 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: _______________ PROTECT THE PERSONAL PRIVACY INTEREST OF PARTIES. AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION FOR WAIVER OR DEFERRAL OF FEES AND COURT COSTS Rev. 09-10 Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com