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Application For Waiver Or Deferral Of Fees And Court Costs - Oregon
| Application For Waiver Or Deferral Of Fees And Court Costs Form. This is a Oregon form and can be used in Regular Division Tax Court Statewide . |
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IN THE OREGON TAX COURT REGULAR DIVISION ___________________________________, ___________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) TC No. ______ APPLICATION FOR WAIVER OR DEFERRAL OF FEE AND COURT COSTS I/We apply for waiver or deferral of the fee. I/We declare that (check item (1) or (2)): (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) Temporary Assistance to Needy Families (TANF). (b) Emergency Assistance (EA). (c) Food stamps. If you checked item (1) above, attach the necessary documentation, skip item (2) below, and sign this application. (2) Based on the attached affidavit, I/we cannot pay the fee and court costs (complete and sign the attached affidavit). If the court defers the fee and costs, I/we understand that: (a) The fee and costs are an obligation owed by me/us to the State of Oregon and that the court may place me/us on a payment schedule. I/we agree to pay the fee and costs APPLICATION FOR WAIVER OR DEFERRAL OF FEE AND COURT COSTS Rev. 10-11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com according to the payment schedule. If I/we fail to pay according to the payment schedule, the total amount of unpaid fee and costs becomes immediately due and payable. (b) The court may enter a judgment against me for the unpaid amount of the fee and other court costs 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 and/or refers a judgment for collection, the law allows administrative and collection costs automatically to be added to the judgment, without further notice to me or further action by the court. _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) _______________________________ (signature) _______________________________ (date) _______________________________ (print or type name) APPLICATION FOR WAIVER OR DEFERRAL OF FEE AND COURT COSTS Rev. 10-11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com IN THE OREGON TAX COURT REGULAR DIVISION ___________________________________, ___________________________________, Plaintiff(s), v. DEPARTMENT OF REVENUE, State of Oregon, Defendant. ) ) ) ) ) ) ) ) ) ) TC No. _____ AFFIDAVIT OF INCOME, ASSETS, AND EXPENSES IN SUPPORT OF APPLICATION FOR WAIVER OR DEFERRAL 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 OR DEFERRAL OF FEE AND COURT COSTS Rev. 10-11 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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 _________________ _________________ _________________ _________________ 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 _____________________________ _____________________________ _____________________________ House payments made to _____________________________ _____________________________ _____________________________ Amount ______________ _____________
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