Fillable Gen-FeeWaiver-Initial Applic-Decl-Instr V2.1 2012-10-25

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Gen-FeeWaiver-Initial Applic-Decl-Instr V2.1 2012-10-25

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Fee Deferral or Waiver Application and Declaration
Page 1 of 3
(Mar 2018)
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF
Case No. _____________________
Plaintiff/Petitioner
v.
APPLICATION FOR DEFERRAL
OR WAIVER OF FEES
& DECLARATION IN SUPPORT
Defendant/Respondent
Applicant’s Full Name:
First Middle Last
ACCESS TO THIS DOCUMENT IS RESTRICTED TO PROTECT THE PRIVACY OF PARTIES
I am the plaintiff/petitioner defendant/respondent other: . I am
unable to pay all or part of the fees right now.
1. I am applying for deferral or waiver of the following fees (check ONE box ONLY):
Filing Fees
Filing fees + sheriff’s service fee*
Motion Fee
Arbitration Fee
Trial Fee
Other (describe):
*If you are requesting deferral or waiver of the sheriff’s service fee, explain why you cannot find
another person to serve the papers. Papers can be served by any competent person who is a
t
l
east 18 years old, a resident of Oregon (or the state where service is made), and who is not
a
p
arty to the case or a party’s lawyer, employee, officer, or director
.
2. If fees are not waived, I understand that payment is a debt to the state of Oregon. Additional
fees may be added for administrative and collection costs.
3. I understand that if the clerk denies my application, I have the right to ask a judge to review
my application.
4. Any waiver or deferral I am granted during the case may be revoked in full or in part at the
end of the case based on the final outcome.
Fee Deferral or Waiver Application and Declaration
Page 2 of 3
(Mar 2018)
Declaration
1. PERSONAL
Date of Birth (month/day/ year)
*SSN: Driver License/State ID:
*I am providing my Social Security number voluntarily. I understand that I cannot be forced to provide it or
be denied consideration solely for failure to provide it. It may be used to verify my identification,
employment information, and for collection of fees.
Number of people living in your household:
2. PUBLIC ASSISTANCE /LEGAL AID
Are you represented in this case by a legal aid attorney?
Yes (Name):
No
C
heck any programs you currently receive assistance from:
(include the amount you receive PER MONTH)
Food Stamps (SNAP-Supplemental Nutrition Assistance Program) - $
Supplemental Security Income (SSI) - $
Temporary Assistance to Needy Families (TANF) - $
Oregon Health Plan (OHP)
Total monthly benefits received:$
Complete sections 3 – 6 with amounts for all members of your household combined
3
.
EMPLOYMENT AND INCOME
Total monthly income from all jobs, before taxes are taken out: $
Total monthly income from other sources: $
(including annuities, settlement income, and any other source of funds or support)
TOTAL INCOME FROM ALL SOURCES: $
4. A
SSET
S
T
otal cash available from all accounts: $____________ (cash, checking account, savings, etc.)
L
ist any assets you have including vehicles, real estate, boats, guns, jewelry, livestock, business
interests, etc.:
Value of assets:
TOTAL VALUE OF ALL ASSETS & CASH: $
0
0
Fee Deferral or Waiver Application and Declaration
Page 3 of 3
(Mar 2018)
5. LIVING EXPENSES (per month)
Home: $
(Rent, mortgage, utilities, cell phone, food)
Transportation: $
(parking, gas, bus, insurance, vehicle loan payments)
Other: $
(student loans, day care, court fines, medical, child support, credit cards, etc.)
TOTAL MONTHLY LIVING EXPENSES: $
6. OTHER INFORMATION YOU WANT COURT TO CONSIDER
Certificate of Document Preparation. Check all that apply:
I chose this form for myself and completed it without paid help
A legal help organization helped me choose or complete this form, but I did not pay money to anyone
I paid (or will pay) for help choosing, completing, or reviewing this form
Guide & File selected and completed this form and I did not pay anyone to review the completed form
I hereby declare that the above statements are true to the best of my knowledge
and belief. I understand they are made for use as evidence in court and I am
subject to penalty for perjury.
Date Signature
Name (printed)
Contact Address City, State, ZIP Contact Phone
0
Fee Deferral or Waiver Order
Page 1 of 2
(Mar 2018)
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF
Case No. ___________________
Plaintiff/Petitioner
v.
ORDER RE: DEFERRAL OR
WAIVER OF FEES
Defendant/Respondent
The court reviewed the Application for Deferral or Waiver of Fees and Declaration in Support
for (Applicant Name):
regarding the following fees:
Filing Fees
Sheriff’s service fee
Motion Fee
Arbitration Fee
Trial Fee
Other: (describe)
The court finds Applicant:
DOES qualify for a deferral or waiver of fees
DOES NOT qualify for a deferral or waiver of fees
Additional findings:
The court orders:
Determination of fee obligation is postponed at this time. No payment is due from the
applicant until further order of the court.
Fees are deferred for full payment. Payment must be made according to the terms of the
attached payment plan (or) $ per month until paid in full
A judgment will be entered against Applicant. Collection costs may be added without
further notice if fees are not paid as ordered.
Fees are waived. The court may change or revoke this waiver at a later time.
Application is denied
Application is granted in part:
J
udge Signature:
Fee Deferral or Waiver Order
Page 2 of 2
(Mar 2018)
Certificate of Readiness
This proposed order is ready for judicial signature because service is not required under UTCR 5.100
because this order is submitted ex parte as allowed by statute or rule
Submitted by: plaintiff/petitioner defendant/respondent other:
Signature Print Name
Certificate of Document Preparation. Check all that apply:
I chose this form for myself and completed it without paid help
A legal help organization helped me choose or complete this form, but I did not pay money to anyone
I paid (or will pay) for help choosing, completing, or reviewing this form
Guide & File selected and completed this form and I did not pay anyone to review the completed form
I
understand that I am subject to penalty for perjury for giving false information to the court.
All factual information in this Order is true to the best of my knowledge and belief. I agree to
the terms of this Order. I understand that this Order is enforceable by the court.
Date Signature
Name (printed)
Contact Address City, State, ZIP Contact Phone
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Gen-FeeWaiver-Initial Applic-Decl-Instr V2.1 2012-10-25

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Completed 24 March 2020

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