Free IN THE CIRCUIT COURT OF THE STATE OF OREGON - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT ______________________________________,
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 Full Name of Applicant ___________________________________________________________________________
FIRST NAME STREET ADDRESS ADDDRESS 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, dependants, or household members (for example: Social Security, unemployment, retirement, public assistance, child support, workers' compensation, disability, tribal benefits, etc.): Source of Income (describe) Amount How long received? How often received? ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________ ______________________________________ $_________ ________________ _________________
Declaration for Waiver or Deferral of Fees OJIN Code: STAS (Statement Assets) Page 1 of 2 FC(1/08)

Other household members who help pay your living expenses: Relationship Amount ______________________________________ $_________ ______________________________________ $_________

Payment for what (describe)? _____________________________________ _____________________________________

3. MONEY ON HAND / IN BANK Cash $____________ Checking Account Number ___________________ Bank/Credit Union ___________________ Balance $ _________ Savings Account Number ____________________ Bank/Credit Union ___________________ Balance $ _________ Other Account Number ______________________ Institution __________________________ Balance $ _________ 4. MOTOR VEHICLES Year, Make, and Model ________________________________ ________________________________ 5. REAL ESTATE Address (include city and state) _____________________________ _____________________________ Year Purchased _______ _______ Purchase Price $_______ $_______ Value $_______ $_______ Amount Owing $_______ $_______ Payments made to: ___________________ ___________________

Value $__________ $__________

Amount Owing $__________ $__________

Payments made to: ___________________________ ___________________________

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 Amount Owed _____________________________________________________________ _____________________________________________________________ 8. MONTHLY LIVING EXPENSES Rent/Mortgage $_____________ Credit Card Payment $________ Child Support Payment $______ Court Fines $_______________ Gas $_________ Water $________ Trash $________ Medical $______ Electric $_________ Sewer $__________ Phone $__________ Food $___________ $___________ $___________

Date Expected _____________ _____________

Vehicle Payment $___________ Vehicle Insurance $__________ Transportation Costs $________ Other _____________ $_______

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

__________________________________________
Signature of Applicant

__________________________________________
Name of Applicant (printed or typed)
Declaration for Waiver or Deferral of Fees OJIN Code: STAS (Statement Assets) Page 2 of 2 FC(1/08)