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Motion For Waiver Or Deferral Of Filing Fee - Oregon
| Motion For Waiver Or Deferral Of Filing Fee Form. This is a Oregon form and can be used in Magistrate Division Tax Court Statewide . |
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IN THE OREGON TAX COURT MAGISTRATE DIVISION , ) ) , ) ) Plaintiff(s), ) Case No. ) versus ) ) COUNTY ASSESSOR, ) MOTION FOR WAIVER OR ) DEFERRAL OF FILING FEE AND / OR (If applicable, circle one; ) if not, cross out Department of Revenue) ) ) DEPARTMENT OF REVENUE, ) AFFIDAVIT OF INDIGENCE State of Oregon, ) ) Defendant. ) MOTION Plaintiff(s) moves the court for waiver or deferral of filing fee in the above case. AFFIDAVIT I (We), the undersigned, duly swear that the following information is true. I (We) ask the court to use the following information to decide whether I (we) can have a waiver or deferral of the $10/$25 filing fee. I (We) 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. NOTE: IN THE EVENT THAT ANY PORTION OF THE FILING FEE REMAINS UNPAID AT THE TIME OF FINAL WRITTEN DISPOSITION OF THIS CASE, THE COURT MAY SEEK ENTRY OF JUDGMENT AGAINST YOU FOR THE UNPAID PORTION OF THE FILING FEE. See ORS 21.605. Complete all requested information (please print or type): 1. Full name(s) Street address City State Zip Home phone Work phone 1 Rev. 7/2003<<<<<<<<<********>>>>>>>>>>>>> 2 1 2. Birth date / / SSN Female Male3. Married Single Separated Divorced 4. Name and address of spouse or nearest relative 5. Names, addresses, ages, and relationship of dependents other than spouse 6. Current or last employer Address How long employed Monthly gross pay Now employed? Yes No 7. If married, your spouses current or last employer Address How long employed Monthly gross pay Now employed? Yes No 8. List all sources of money besides employment pay for you and your spouse; for example, social security, unemployment compensation, retirement benefits, workers compensation, public assistance, child support, alimony: 9. Real estate owned by you and your spouse: Address What it is worth Amount you owe on it Automobiles and other motor vehicles owned by you and your spouse: Vehicle Vehicle What it is worth What it is worth Amount you owe Amount you owe 1 Although it may assist the court in verifying the information you are submitting in support of the motion, you cannot be required to provide your social security number. 2 Rev. 7/2003<<<<<<<<<********>>>>>>>>>>>>> 3 Bank or savings account, including credit unions, owned by you or your spouse 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 Money owed to you or your spouse by others: Name of debtor Amount owed 10. Monthly expenses: Rent/House Pmt $ Department stores $ Food $ Doctors/Medical $ Utilities $ $ Car payment $ $ 11. I (We) receive food stamps Yes No If yes, current eligibility amount $ 12. Any other facts or circumstances affecting your ability to pay the filing fee? Date: Signature: Date: Signature: Subscribed and sworn before me this day of , . (Clerk/Notary/Judge) NOTE: THIS MOTION MUST BE SUBMITTED WITH YOUR COMPLAINT. PROVIDE THE ORIGINAL AND ONE COPY. 3 Rev. 7/2003
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