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Application For Waiver Or Fees And Court Costs - Oregon

Application For Waiver Or Fees And Court Costs Form. This is a Oregon form and can be used in Magistrate Division Tax Court Statewide .
 Fillable pdf Last Modified 10/16/2014
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IN THE OREGON TAX COURT MAGISTRATE DIVISION ___________________________________, ___________________________________, Plaintiff(s), v. Note: Identify the defendant(s) named in your complaint. ________________ COUNTY ASSESSOR DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) TC-MD___________________ ) ) ) ) ) ) ) ) ) ) DECLARATION AND APPLICATION ) FOR WAIVER OF FEE I/We ask for waiver of fee in this case because I/we am/are unable to pay all or part of the fee. (The fee is $252.) I/We understand that I/we must complete the Declaration below and provide the requested documentation to prove to the court that I/we do not have enough money to pay the fee. I/We understand that if I/we do not, my/our request can be denied. Declaration (1) PERSONAL INFORMATION Applicant 1 (full name: last, first, middle initial) (driver license number) (street address) (city) ________________ __________________ (date of birth) (marital status) _______ - ________ - _________ (Social Security number*) (state) (ZIP) (telephone number) (mailing address, if different from above) Applicant 2 (full name: last, first, middle initial) (driver license number) (street address) (city) ________________ __________________ (date of birth) (marital status) _______ - ________ - _________ (Social Security number*) (state) (ZIP) (telephone number) (mailing address, if different from above) * 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. DECLARATION AND APPLICATION FOR WAIVER OF FEE Rev. 10/13 W 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Names and ages of legal dependents living in household: Name ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ (2) PUBLIC ASSISTANCE I/We declare that (check either box (1) or (2) below): Age _____ _____ _____ _____ _____ (1) I/We receive public benefits under one of the following programs (you must provide proof of current eligibility for any program checked below). (a) (b) (c) (d) Temporary Assistance to Needy Families (TANF). Food Stamps-Supplemental Nutrition Assistance Program (SNAP). Supplemental Security Income (SSI). Oregon Health Plan (OHP) package: 1. OHP Plus; 2. OHP Standard; or 3. OHP with limited drug. If you checked box (1) above, attach the necessary documentation. If you claim to be eligible for public assistance, you must show proof of the amount you receive from all programs. (2) Even though I/we do NOT receive assistance from any of the above programs, I/we cannot pay the fee. (3) EMPLOYMENT AND OTHER INCOME Your Employment and Income Present employer, if currently employed Not currently employed. How long since last employment?_______ Present/Past Employer ___________________________ How long? _________ Occupation (title) ____________ Address _____________________________________________ Work phone _____________________________ Hourly wage _________ Hours per week _________ Monthly pay: gross ______ or net (after taxes) _______ Last paycheck $______________ (If you are employed, you must show proof of your income. You must show proof of income for the past two months.) Household Members' Employment and Income Name and relationship to you:____________________________________________________________________ Present employer, if currently employed Not currently employed. How long since last employment?_______ Present/Past Employer ___________________________ How long? _________ Occupation (title) ____________ Address _____________________________________________ Work phone _____________________________ Hourly wage _________ Hours per week _________ Monthly pay: gross ______ or net (after taxes) _______ Last paycheck $______________ Any other income for you, household members, or dependents in addition to amounts listed in Section 2 above (for example: Social Security, unemployment, retirement, public assistance, child or spousal support, workers' compensation, disability, tribal benefits, etc.): Source of Income (describe) Amount ________________________________ ______________ ________________________________ ______________ ________________________________ ______________ DECLARATION AND APPLICATION FOR WAIVER OF FEE How long received __________________ __________________ __________________ How often received _________________ _________________ _________________ Rev. 10/13 W 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com (4) MONTHLY LIVING EXPENSES Home Rent/Mortgage: $_________________________ Food: $___________________ Trash: $_____________________ Utilities Electric: $___________________ Gas: $___________________ Water: $___________________ Sewer: $___________________ Phone: $___________________ Cell: $___________________ Cable: $___________________ Internet: $___________________ Transportation Vehicle payments: $___________________ Insurance: $___________________ Gas: $___________________ Bus: $___________________ Parking: $___________________ Other Credit cards: $___________________ Student loans: $___________________ Court fines: $__________________ Medical: $___________________ Child Support: $___________________ Other (describe):_______________________________________________________________________________ (You must show proof of amount you pay for monthly expenses. You must show proof of expenses for the past two months.) Any other individuals who help pay your living expenses: Relationship Amount _________________________________ ____________ _________________________________ ____________ _________________________________ ____________ (5) MONEY ON HAND / IN BANK Cash _______________________ Checking Account No.___________ Bank/Credit Union_________________________ Balance ______________ Savings Account No.___________ Bank/Credit Union_________________________ Balance ______________ Other Account No.___________ Bank/Credit Union_________________________ Balance ______________
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