Oregon > Statewide > Tax Court > Magistrate Division
Plaintiffs Application For Waiver Of Filing Fee - Oregon
| Plaintiffs Application For Waiver Of Filing Fee Form. This is a Oregon form and can be used in Magistrate Division Tax Court Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
IN THE OREGON TAX COURT MAGISTRATE DIVISION _________________________________, _________________________________, Plaintiff(s), v. Note: Identify the defendant(s) named in your complaint. ________________ COUNTY ASSESSOR G DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) TC-MD _______________ PLAINTIFF'S(S') APPLICATION FOR WAIVER OF FILING FEE I/We apply for waiver of the $25 filing fee. I/We declare that (check item (1) or (2)): G (1) I/We receive public benefits under one of the following programs (you must provide proof of current eligibility for any program checked below). G (a) Temporary Assistance to Needy Families (TANF). G (b) Emergency Assistance (EA). G (c) Food stamps. If you checked item (1) above, attach the necessary documentation, skip item (2) below, and sign this application. G (2) Based on the attached affidavit, I/we cannot pay the filing fee (complete and sign the attached affidavit). (signature) (print or type name) (date) (signature) (print or type name) APPLICATION FOR W AIVER OF FILING FEE (date) Rev. 01/08 Page 1 of 1 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 G DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) TC-MD _______________ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION TO WAIVE FILING FEE ________________________________________ ____________________________________ (full name: last, first, middle initial) (driver license number) (full name: last, first, middle initial) (date of birth) (Social Security number*) (date of birth) __________________________________ _______ - ________ - _________ ________________________________________ ____________________________________ _________________________________ (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) EM PLOYM ENT AND OTHER INCOM E G Present employer, if currently employed G Previous employer, if not currently employed. How long since last employment? ______________________________ Employer __________________________________ How long? _________ Occupation (title) ________________ Address _____________________________________________ W ork phone _____________________________ Hourly wage _________ Hours per week __________ Monthly pay: G gross ______ or G net (after taxes) _______ G Spouse's present employer, if currently employed G Previous employer, if not currently employed. How long since last employment? _______________ Employer __________________________________ How long? _________ Occupation (title) ________________ Address _____________________________________________ W ork phone _____________________________ Hourly wage _________ Hours per week __________ Monthly pay: G gross ______ or G net (after taxes) _______ Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com G 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, etc.: Source of Income (describe) ________________________________ ________________________________ ________________________________ ________________________________ Amount ______________ ______________ ______________ ______________ How long received __________________ __________________ __________________ __________________ How often received _________________ _________________ _________________ _________________ G Other household members who help pay for your living expenses: Relationship ________________________________ ________________________________ ________________________________ ________________________________ (2) M ONEY 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) M OTOR VEHICLES Make and year __________________________________ __________________________________ __________________________________ (4) REAL ESTATE Address and city __________________________________ __________________________________ __________________________________ Value ___________ ___________ ___________ Value ___________ ___________ ___________ Amount owing ____________ ____________ ____________ Amount owing ____________ ____________ ____________ Vehicle payments made to _____________________________ _____________________________ _____________________________ House payments made to _____________________________ _____________________________ _____________________________ Amount ______________ ______________ ______________ ______________ Payment for what? (describe) _______________________________________ _______________________________________ _______________________________________ _______________________________________ (5) ALL OTHER PROPERTY OR ASSETS (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 __________________________________ __________________________________ _________ _________ __________________________________ __________________________________ __________ __________ (6) M ONEY OW ED TO YOU BY OTHERS (for example, tax refund, settlement, judgment, trust funds) Name of debtor Amount owed Date expected ________________________________________________ _______________________ _________________ ________________________________________________ ________________________________________________ _______________________ _______________________ _________________ _________________ (7) NUM BER OF DEPENDENTS IN HOUSEHOLD: _____________
|
|||||||
