Free Declaration for Waiver or Deferral of Fees (eff. 1-1-08) - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _______________________ ____________________________________ ) Petitioner/Plaintiff, ) ) v. ) ) ____________________________________ ) Respondent/Defendant. ) Case No. _________________ Petitioner/Plaintiff Respondent/Defendant DECLARATION FOR WAIVER OR DEFERRAL OF FEES

(TO BE COMPLETED BY APPLICANT) ACCESS TO THIS DOCUMENT IS RESTRICTED PURSUANT TO THE COURT'S POLICY TO PROTECT THE PERSONAL PRIVACY INTERESTS OF PARTIES 1. PERSONAL Name of Applicant _________________________________________________________________________________
FIRST NAME STREET ADDRESS STREET ADDRESS MIDDLE NAME CITY CITY LAST NAME STATE STATE ZIP ZIP

Residence Address ________________________________________________________________________________ Mailing Address (if different) _________________________________________________________________________ Telephone Number __________________*SSN _______________ODL/ID _____________Marital Status ___________
*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 failure to provide it. It may be used to verify my identification, credit and employment information, and for collection purposes of court imposed monetary obligations.

Names and ages of legal dependants living in household: Name Age _________________________________ ______ _________________________________ ______ _________________________________ ______

Name _________________________________ _________________________________ _________________________________

Age ______ ______ ______

2. EMPLOYMENT AND INCOME Currently Employed Not Currently Employed How long since last employment? __________________ Employer Name (use previous employer if not currently employed) ___________________________________________ Employer Address _________________________________________________________ Work Phone ______________ Occupation (job title) ___________________ Length of Employment ____________ Amount of Last Paycheck $ _______ Hourly Wage $ _________ Hours Per Week _________ Monthly Income: Gross $ _________ Net (after taxes) $ _______ Spouse's Employment Currently Employed Not Currently Employed How long since last employment? __________________ Employer Name (use previous employer if not currently employed) ___________________________________________ Employer Address _________________________________________________________ Work Phone ______________ Occupation (job title) ___________________ Length of Employment ____________ Amount of Last Paycheck $ _______ Hourly Wage $ _________ Hours Per Week _________ Monthly Income: Gross $ _________ Net (after taxes) $ _______ Other income for you, spouse, dependents, or household members (for example: Social Security, unemployment, retirement, public assistance, child support, workers' compensation, disability, tribal benefits, etc.): Source of Income (describe) __________________________________ __________________________________ __________________________________
Declaration for Waiver or Deferral of Fees OJIN Code: STAS (Statement of Assets)

Amount $__________ $__________ $__________

How long received? __________________ __________________ __________________

How often received? ___________________ ___________________ ___________________
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Other household members who help pay your living expenses: Relationship ____________________________________ ____________________________________ 3. MONEY ON HAND / IN BANK Cash $ ______________ Checking Account Number ________________ Bank/Credit Union _____________________ Balance $ ____________ Savings Account Number _________________ Bank/Credit Union _____________________ Balance $ ____________ Other Account Number ___________________ Bank/Credit Union _____________________ Balance $ ____________ 4. MOTOR VEHICLES Year, Make, and Model ____________________________________ ____________________________________ 5. REAL ESTATE Address (include city and state) ___________________________ ___________________________ Year Purchased ________ ________ Purchase Price $_________ $_________ Amount Value Owing Payments made to: $_________ $_________ _____________________ $_________ $_________ _____________________ Value $__________ $__________ Amount Owing $_______________ $_______________ Payments made to: _________________________ _________________________ Amount $___________ $___________ Payment for what (describe)? ______________________________________ ______________________________________

6. ALL OTHER PROPERTY OR ASSETS (for example: ATVs, RVs, boats, guns, jewelry, livestock, etc.): Description ____________________________ ____________________________ ____________________________ Value $___________ $___________ $___________ Description ____________________________ ____________________________ ____________________________ Value $__________ $__________ $__________

7. MONEY OWED TO YOU BY OTHERS (for example: tax refunds, judgments, trust funds, etc.): Name of Debtor Owing You Money _______________________________________________________ _______________________________________________________ 8. MONTHLY LIVING EXPENSES Rent/Mortgage $ _______________ Credit Card Payment $ __________ Child Support Payment $ ________ Court Fines $ __________________ 9. LIQUIDATION OF ASSETS If you are unable to sell or liquidate your assets, please use this space to explain why: ____________________________ _________________________________________________________________________________________________ I hereby declare that the above statement is true to the best of my knowledge and belief. I understand that it is made for use as evidence in court and is subject to penalty for perjury. _________________________________
Date

Amount Owed $_____________ $_____________

Date Expected __________________ __________________

Gas $ __________ Water $ ________ Trash $ ________ Medical $ _______

Electric $ ________ Sewer $ _________ Phone $ _________ Food $ __________

Vehicle Payment $ __________ Vehicle Insurance $ _________ Transportation Costs $ _______ Other ____________ $ ______

__________________________________________________
Signature of Applicant

__________________________________________________
Name of Applicant (printed or typed) Declaration for Waiver or Deferral of Fees OJIN Code: STAS (Statement of Assets) Page 2 of 2