IN THE OREGON TAX COURT REGULAR DIVISION _________________________________, _________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) ) ) Case No. ______ Check one or both: G MOTION FOR WAIVER OR DEFERRAL OF FILING FEE, AFFIDAVIT OF INDIGENCE, AND AFFIDAVIT OF UNDUE HARDSHIP G MOTION FOR STAY OF PAYMENT OF INCOME TAX AND AFFIDAVIT OF UNDUE HARDSHIP Initial the following Motion(s) and Affidavit(s) you are submitting to the court: MOTION FOR WAIVER OR DEFERRAL OF FILING FEE Plaintiff(s) moves the court for waiver or deferral of filing fee in the above case. ________ ________ Initials Initials AFFIDAVIT OF INDIGENCE I (We), the undersigned, duly swear that the following information is true. I (We) ask the court to use the information in the Affidavit of Undue Hardship to decide whether I (we) can have a waiver or deferral of the $50 filing fee. 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. NOTE: IN THE EVENT THAT ANY PORTION OF THE FILING FEE, AFTER GIVING EFFECT TO ANY WAIVER, REMAINS UNPAID AT THE TIME OF FINAL WRITTEN DISPOSITION OF THIS CASE, THE COURT MAY SEEK ENTRY OF JUDGMENT AGAINST YOU FOR THE UNPAID PORTION OF THE FILING FEE. See ORS 21.605. ________ ________ Initials Initials MOTION FOR STAY OF PAYMENT OF INCOME TAX Plaintiff(s) moves the court for an order finding undue hardship and temporarily staying the payment of income tax, penalties, and interest in the above case. ________ ________ Initials Initials Page 1 of 4 Rev. 09-07 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF UNDUE HARDSHIP I (We), the undersigned, duly swear that the following information is true. I (We) ask the court to use the following information to determine that requiring me (us) to pay the income taxes, penalties, and interest prior to filing a complaint in the Tax Court would constitute an undue hardship. 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. ________ ________ Initials Initials Complete all requested information (please print or type): (1) Full name(s) ________________________________________________________________ Street address _________________________________________________________________ City State Zip _________________________________________________________________ Home phone _______________________ Work phone ______________________________ (2) Birth date ____ /____ /_____ SSN1_______ _______ _______ G Female G Male (3) G Married G Single G Separated G Divorced (4) Name and address of spouse ___________________________________________________ ____________________________________________________________________________ (5) Names, addresses, ages, and relationship of dependents other than spouse _______________ ____________________________________________________________________________ ____________________________________________________________________________ (6) Current or last employer ______________________________________________________ Address _____________________________________________________________________ How long employed _____________________ Monthly gross pay _____________________ Now employed? GYes G No 1 Although it may assist the court in verifying the information you are submitting in support of the motion, you cannot be required to provide your social security number. Page 2 of 4 Rev. 09-07 American LegalNet, Inc. www.FormsWorkflow.com (7) If married, your spouse's current or last employer __________________________________ Address _____________________________________________________________________ How long employed ____________________ Monthly gross pay _______________________ Now employed? GYes G No (8) List all sources of money besides employment pay for you and your spouse; for example, social security, unemployment compensation, retirement benefits, workers' compensation, public assistance, child support, alimony: ___________________________________________ ____________________________________________________________________________ (9) Real estate owned by you and your spouse: _______________________________________ Address _____________________________________________________________________ What it is worth ____________________ Amount you owe on it _______________________ (10) Automobiles and other motor vehicles owned by you and your spouse: Vehicle _______________________________ Vehicle _______________________________ What it is worth _____________________ What it is worth ____________________________ Amount you owe ____________________ Amount you owe ___________________________ (11) Bank or savings account, including credit unions, owned by you or your spouse ______________________________________________________________________________ ______________________________________________________________________________ (12) 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 _______________________________ Money owed to you or your spouse by others: _______________________________________ Name of debtor __________________________________ Amount owed ________________ Page 3 of 4 Rev. 09-07 American LegalNet, Inc. www.FormsWorkflow.com (13) Monthly expenses: Rent/House Payment $ Department stores Food $ Credit Card Payment(s) $ Utilities $ Doctors/Medical $ Car Payment(s) $ Other __________ $ (14) I (We) receive food stamps GYes $ G No If yes, current eligibility amount $ ____________ (15) Any other facts or circumstances affecting your ability to pay the filing fee and/or the taxes, penalties, and interest: __________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Date: _____________________ Signature: _________________________________________ Date: _____________________ Signature: _________________________________________ Subscribed and sworn before me this day of , . Notary Public for Oregon My Commission Expires:_______________ IMPORTANT: You must sign this motion in the presence of a notary public. NOTE: This motion or motions and accompanying affidavits must be submitted with your Complaint. Page 4 of 4 Rev. 09-07 American LegalNet, Inc. www.FormsWorkflow.com