Oregon > Local County > Jackson > Circuit Court
Application For Deferral Or Waiver Of Fees - Oregon
| Application For Deferral Or Waiver Of Fees Form. This is a Oregon form and can be used in Circuit Court Jackson Local County . |
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Jackson County Circuit Court, 100 S. Oakdale, Medford, OR 97501 541-776-7171 Instructions for Fee Deferral or Waiver Applications and Declarations If you want to apply for a deferral or waiver of fees, you must complete the attached forms (Application and Declaration of Assets). ALL SPACES on the Application and Declaration must be complete. If you are receiving public assistance, proof MUST be attached to your Declaration of Assets. We will not make copies of the proof provided so if you wish to keep a copy for your records, please make a photocopy before submitting your documents to court. Acceptable proof includes one of the following: · Food Stamps computer printout of "issuance history" stamped by DHS, your Oregon Trail card is not acceptable proof. · TANF computer printout of "issuance history" stamped by DHS. · Oregon Health Plan (Standard, Plus, or w/Limited Drug) current print out of the Medical Card obtained from DHS. · Supplemental Security & Disability Income a Benefit Verification Letter from Social Security Administration that includes ALL of the following: 1. Type of claim (supplemental, disability, etc.) 2. Date benefits began 3. Monthly benefit amount 4. Stamp and initials of Social Security Administration Staff. Proof may be obtained at the offices below: DHS Medford 800 Cardley Ave. Medford, OR 97504 541-776-6172 DHS Ashland 1658 Ashland St. Ashland, OR 97520 541-482-2041 DHS White City 3131 Avenue C White City, OR 97503 541-864-8700 Social Security 3501 Excel Dr. # 101 Medford, OR 97504 866-931-7943 APPLICATIONS THAT ARE INCOMPLETE OR MISSING THE REQUIRED PROOF STATED ABOVE WILL RESULT IN A DENIAL OF THE FEE DEFERRAL OR WAIVER. Public Flyer Fee Waiver Instructions Page 1 of 1 9/23/11 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY _________________________________ Petitioner/Plaintiff vs. __________________________________ Respondent/Defendant Case No. _________________ Petitioner/Plaintiff Respondent/Defendant APPLICATION FOR DEFERRAL OR WAIVER OF FEES I am asking for deferral or waiver of fees in this case because I am unable to pay all or part of the fees. The following information is complete and accurate to the best of my knowledge. I understand that I may be required to provide documentation verifying this information. I understand that failure to do so could result in my request being denied. You must complete the attached Declaration for Deferral or Waiver of Fees with this application. The declaration is designed to prove to the court that you do not have sufficient financial resources to pay the fees. 1. I am applying for deferral or waiver of the following fees (check ALL that apply): Filing Fee Hearing/Non-Jury Trial Fee Arbitration Fee Note: Sheriff's Service Fee Parenting Class Visitors' Fee Guardianship, conservatorship and probate fees are limited to waiver or full payment; Guardianship and conservatorship cases are based on "Protected" person's information; Probate cases are based on "Deceased" person's information. 2. I declare that (check one of the boxes below): I am receiving assistance from the following program (check ALL that apply): Food Stamps (SNAP) Oregon Health Plan Standard Oregon Health Plan Plus Oregon Health Plan with Limited Drug Supplemental Security & Disability Income Temporary Assistance to Needy Families (TANF) Note: If you checked the above box, you must show proof that you are receiving assistance from the program. Even though I am NOT receiving assistance from any of the above programs, I am still unable to pay the fees. Supporting Documentation Verified on ___/___/20___ ___ No Proof Provided By ___________________ Public Civil Fee Deferral Waiver Application Page 1 of 2 08/01/11 OJIN code: AE American LegalNet, Inc. www.FormsWorkFlow.com 3. If the court defers fees, I understand that: a. The fees are an obligation owed by me to the State of Oregon and that the court may place me on a payment schedule. I agree to pay the fees according to the payment schedule. If I fail to pay according to the payment schedule, the total amount of the unpaid fees are due immediately. b. The court may enter a judgment against me for the unpaid amount of the fees 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 or refers a judgment for collection, the law allows administrative and collection costs to be automatically added to the judgment without further notice to me or further action by the court. d. The above deferral or waiver pertains only to filing, hearing, non-jury trial, parenting class, visitor, arbitration, and Sheriff's service fees; you are still responsible for paying jury trial fees. 4. I understand that if the clerk denies my application, I have the right to ask a judge to review my application. ____ /____ /20___ Date ________________________________________ Signature of Applicant ________________________________________ Name of Applicant (printed or typed) ________________________________________ Address ________________________________________ City, State, Zip (___ )___________________________________ Telephone Number Public Civil Fee Deferral Waiver Application Page 2 of 2 08/01/11 OJIN code: AE American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY _________________________________ Petitioner/Plaintiff vs. __________________________________ Respondent/Defendant Case No. _________________ Petitioner/Plaintiff Respondent/Defendant DECLARATION FOR DEFERRAL OR WAIVER OF FEES (TO BE COMPLETED BY APPLICANT IN ITS ENTIRETY INCLUDING "N/A" or "0" WHEN APPROPRIATE INCOMPLETE FORMS COULD CAUSE DENIAL OF YOUR REQUEST FOR FEE WAIVER OR DEFERRAL) ACCESS TO THIS DOCUMENT IS RESTRICTED PURSUANT TO THE COURT'S POLICY TO PROTECT THE PERSONAL PRIVACY INTERESTS OF PARTIES 1. PERSONAL Please check if EMERGENCY consideration is needed for this filing Full Name of Applicant _______________________________________________________________ FIRST NAME MIDDLE NAME LAST NAME Residence Address ___________________________________________________________________ STREET ADDRESS CITY STATE ZIP Mailing Address (if different) ___________________________________________________________ STREET ADDRESS CITY STATE ZIP Telephone#_____________ *SSN _____________ ODL/ID __________ Birthdate __________Marital Status ___ *I am providing my Soci
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