Free Application for Waiver or Deferral of Filing Fee - Oregon

IN THE OREGON TAX COURT REGULAR DIVISION _________________________________, _________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. I/We apply for waiver or deferral of the G Filing fee of $50. G Other fee (specify) ________ in the amount of $ ________. I/We declare that (check item (1) or (2)): G (1) I/We receive public benefits under one of the following programs (you must provide proof of current eligibility for any program checked below). G (a) Temporary Assistance to Needy Families (TANF). G (b) Emergency Assistance (EA). G (c) Food stamps. If you checked item (1) above, attach the necessary documentation, skip item (2) below, and sign this application. G (2) Based on the attached affidavit, I/we cannot pay the fees and court costs (complete and sign the attached affidavit). 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 costs according to the payment schedule. If I/we fail to pay according to the payment
APPLICATION FOR WAIVER OR DEFERRAL OF FILING FEES AND COURT COSTS
Rev. 01/08

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TC No. ______

APPLICATION FOR WAIVER OR DEFERRAL OF FILING FEES AND COURT COSTS

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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 the filing fee 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.

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APPLICATION FOR WAIVER OR DEFERRAL OF FILING FEES AND COURT COSTS

Rev. 01/08

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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 FILING FEES AND COURT COSTS

________________________________________ ____________________________________
(full name: last, first, middle initial) (driver license number) (full name: last, first, middle initial) (date of birth) (Social Security number*) (date of birth)

__________________________________ _______ - ________ - _________ ________________________________________ ____________________________________ _________________________________
(driver license number) (street address)

_______ - ________ - _________
(Social Security number*)

___________________________________________________

________________________
(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 APPLICATION FOR W AIVER OR DEFERRAL OF FILING FEES AND COURT COSTS
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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 ________________________________ ________________________________ ________________________________ ________________________________ (2) M ONEY ON HAND/IN BANK Cash _______________________ Checking Account No.___________ Bank/Credit Union_________________________ Balance ______________ Savings Account No.___________ Other Account No.___________ Bank/Credit Union_________________________ Balance ______________ Bank/Credit Union_________________________ Balance ______________ Value ___________ ___________ ___________ Value ___________ ___________ ___________ Amount owing ____________ ____________ ____________ Amount owing ____________ ____________ ____________ Vehicle payments made to _____________________________ _____________________________ _____________________________ House payments made to _____________________________ _____________________________ _____________________________ Amount ______________ ______________ ______________ ______________ Payment for what? (describe) _______________________________________ _______________________________________ _______________________________________ _______________________________________

(3) M OTOR VEHICLES Make and year __________________________________ __________________________________ __________________________________ (4) REAL ESTATE Address and city __________________________________ __________________________________ __________________________________

(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 APPLICATION FOR W AIVER OR DEFERRAL OF FILING FEES AND COURT COSTS
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(8) LIVING EXPENSES Rent/Mortgage ______________ Utilities Food Vehicle payment(s) Medical Expenses Credit card payment(s) Department stores Other Other TOTAL ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

(9) OTHER INFORM ATION THE COURT SHOULD KNOW ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

Child support payment(s) ______________

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 APPLICATION FOR W AIVER OR DEFERRAL OF FILING FEES AND COURT COSTS

Rev. 01/08

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