IN THE OREGON TAX COURT REGULAR DIVISION Income Tax _________________________________, _________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) ) TC No. ______ MOTION FOR STAY OF PAYMENT OF INCOME TAX Plaintiff(s) moves the court for an order finding undue hardship based on the attached affidavit and temporarily staying the payment of income tax, penalties, and interest in the above case. (signature) (date) (print or type name) (signature) (date) (print or type name) MOTION FOR STAY OF PAYMENT OF INCOME TAX Rev. 01/08 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com IN THE OREGON TAX COURT REGULAR DIVISION Income Tax _________________________________, _________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) ) TC No. ______ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF MOTION FOR STAY OF PAYMENT OF INCOME TAX ________________________________________ ____________________________________ (full name: last, first, middle initial) (date of birth) __________________________________ _______ - ________ - _________ (driver license number) (Social Security number*) ________________________________________ ____________________________________ (full name: last, first, middle initial) (date of birth) _________________________________ (driver license number) _______ - ________ - _________ (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) EM PLOYM ENT AND OTHER INCOM E G Present employer, if currently employed G Previous employer, if not currently employed. How long since last employment? ______________________________ Employer __________________________________ How long? _________ Occupation (title) ________________ Address _____________________________________________ W ork phone _____________________________ Hourly wage _________ Hours per week __________ Monthly pay: G gross ______ or G net (after taxes) _______ G Spouse’s present employer, if currently employed G Previous employer, if not currently employed. How long since last employment? _______________ Employer __________________________________ How long? _________ Occupation (title) ________________ Address _____________________________________________ W ork phone _____________________________ Hourly wage _________ Hours per week __________ Monthly pay: G gross ______ or G net (after taxes) ______ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF MOTION FOR STAY OF PAYMENT OF INCOME TAX Rev. 01/08 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com G 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 _________________ ________________________________ ______________ __________________ _________________ ________________________________ ______________ __________________ _________________ ________________________________ ______________ __________________ _________________ G Other household members who help pay for your living expenses: Relationship ________________________________ Amount ______________ Payment for what? (describe) _______________________________________ ________________________________ ______________ _______________________________________ ________________________________ ______________ _______________________________________ ________________________________ ______________ _______________________________________ (2) M ONEY 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) M OTOR 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) M ONEY OW ED TO YOU BY OTHERS (for example, tax refund, settlement, judgment, trust funds) Name of debtor Amount owed Date expected ________________________________________________ _______________________ _________________ ________________________________________________ _______________________ _________________ ________________________________________________ _______________________ _________________ (7) NUM BER OF DEPENDENTS IN HOUSEHOLD: ______________ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF MOTION FOR STAY OF PAYMENT OF INCOME TAX Rev. 01/08 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com (8) LIVING EXPENSES Rent/Mortgage ______________ (9) OTHER INFORM ATION THE COURT SHOULD KNOW Utilities ______________ ______________________________________________________ Food ______________ ______________________________________________________ Vehicle payment(s) ______________ ______________________________________________________ Medical Expenses ______________ ______________________________________________________ Child support payment(s) ______________ ______________________________________________________ Credit card payment(s) ______________ ______________________________________________________ Department stores ______________ ______________________________________________________ Other ______________ ______________________________________________________ Other ______________ ______________________________________________________ ______________ ______________________________________________________ TOTAL ______________________________________________________ IMPORTANT: You must sign this affidavit in the presence of a notary public. I/W e 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/W e 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 SW ORN before me this ______ day of _________________, ___________. ____________________________________ Notary Public for Oregon My Commission Expires:________________ ACCESS TO THIS DOCUM ENT IS RESTRICTED PURSUANT TO THE COURT’S POLICY TO PROTECT THE PERSONAL PRIVACY INTEREST OF PARTIES. AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF MOTION FOR STAY OF PAYMENT OF INCOME TAX Rev. 01/08 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com