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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 4/4/2012
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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___________________ ) ) ) ) ) ) ) ) ) ) APPLICATION FOR WAIVER OF FEE ) AND COURT COSTS I/We request waiver of fee in this case because I/we cannot pay all or part of the fee. (The fee is $240.) The following information is complete and accurate to the best of my/our knowledge. I/We understand that I/we may be required to provide documentation verifying this information. I/We understand that failure to do so could result in my/our request being denied. You must complete the Affidavit of Income, Assets, and Expenses In Support of Application for Waiver of Fee and Court Costs with this application. The affidavit is designed to prove to the court that you do not have sufficient financial resources to pay the fee. I/We declare that (check one of the boxes below): (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 item (1) above, attach the necessary documentation and sign this application. APPLICATION FOR WAIVER OF FEE AND COURT COSTS Rev. 10/11 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (2) Even though I/we do NOT receive assistance from any of the above programs, I/we cannot pay the fee and court costs. Based on the attached affidavit, I/we cannot pay the fee and court costs (complete and sign the attached affidavit). _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) APPLICATION FOR WAIVER OF FEE AND COURT COSTS Rev. 10/11 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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___________________ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION FOR WAIVER OF FEE AND COURT COSTS (date of birth) (Social Security number*) (date of birth) ________________________________________ ____________________________________ (full name: last, first, middle initial) (driver license number) (full name: last, first, middle initial) __________________________________ _______ - ________ - _________ ________________________________________ ____________________________________ _________________________________ (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) EMPLOYMENT AND OTHER INCOME Present employer, if currently employed Previous employer, if not currently employed. How long since last employment?______________________________ Employer __________________________________ How long? _________ Occupation (title) _______________ Address _____________________________________________ Work phone _____________________________ Hourly wage _________ Hours per week _________ Monthly pay: gross ______ or net (after taxes) _______ Spouse's present employer, if currently employed Previous employer, if not currently employed. How long since last employment?_______________ Employer __________________________________ How long? _________ Occupation (title) ________________ Address _____________________________________________ Work phone______________________________ Hourly wage _________ Hours per week __________ Monthly pay: gross ______ or net (after taxes)_______ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION FOR WAIVER OF FEE AND COURT COSTS Rev. 10/11 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com etc.: 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, Source of Income (describe) ________________________________ ________________________________ ________________________________ ________________________________ Amount ______________ ______________ ______________ ______________ How long received __________________ __________________ __________________ __________________ How often received _________________ _________________ _________________ _________________ Other household members who help pay for your living expenses: Relationship ________________________________ ________________________________ ________________________________ ________________________________ (2) 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 ______________ (3) MOTOR VEHICLES Make and year __________________________________ __________________________________ __________________________________ (4) REAL ESTATE Address and city __________________________________ __________________________________ __________________________________ Value ___________ ___________ ___________ Value ___________ ___________ ___________ Amount owing ____________ ____________ ____________ Amount owing ____________ ____________ ____________ Vehicle payments made to _____________________________ _____________________________ _________________________
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