Affidavit In Support Of Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs | Pdf Fpdf Doc Docx | Oregon

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Affidavit In Support Of Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs | Pdf Fpdf Doc Docx | Oregon

Affidavit In Support Of Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs

This is a Oregon form that can be used for Guardianship within Local County, Marion, Circuit Court, Probate.

Alternate TextLast updated: 5/11/2006

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IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF MARION Probate DepartmentIn the Matter of the ) Case No. ____________Guardianship of ) ) AFFIDAVIT IN SUPPORT OF MARION COUNTY _____________________, ) INDIGENT GUARDIANSHIP FUND APPLICATION Respondent. ) AND/OR MOTION TO WAIVE FEES AND COSTSSTATE OF OREGON ) County of ______________ ) I hereby swear or affirm that I am or intend to be the Petitioner in the above matter and provide to theCourt the following information: 1. The Respondent has no or insufficient financial resources which could be utilized to pay forthe expense of establishing a guardianship for the Respondent. 2. If I am related to the Respondent by blood or marriage, I have no or insufficient financialresources which could be utilized to pay for the expense of establishing a guardianship for the Respondent. 3. I have reviewed and am familiar with the eligibility requirements and the compensationguidelines for the Marion County Indigent Guardianship Fund.=============================================================================SECTION A - TO BE COMPLETED BY ALL APPLICANTS The source and amount of the income of the Responde_________________________________nt is _____________________________________________________________________________________ The type and value of the assets of the Respondent (including bank accounts, funds held by others, realestate, autos, stocks, etc.) are: _________________________________________________________________________________________________________________________________________________ The nature and amount of the expenses of the Respondent_______________________________ are __________________________________________________________________________________________________________________________________________________________________________ Describe the Respondents current medical, physical and/or mental condition which necessitates theappointment of a Guardian _____________________________________________________________________________________________________________________________________________________ Describe what other efforts have been made to obtain guardianship or other medical decision makingauthority for the Respondent______________________________________________________________ _____________________________________________________________________________________ Describe what other efforts have been made to get funds to pay for the costs of obtaining aguardianship for the Responde___________________________________________________________nt _____________________________________________________________________________________ Is the Respondent a client of Senior Services, Mental Health, Disability Services, or other State,County, or local agency ________. If Yes, which agen_________________________________________cy Does the Respondent currently receive Medicaid or SSI benefits (Y____________/N) Is the Respondent currently employed (Y/____________N)Page 1 - AFFIDAVIT IN SUPPORT OF MARION COUNTY INDIGENT GUARDIANSHIPFUND APPLICATION AND/OR MOTION TO WAIVE FEES AND COSTSAPPLICAT.WPD (Last Revised 5/3/01) <<<<<<<<<********>>>>>>>>>>>>> 2=========================================================================== SECTION B - TO BE COMPLETED BY APPLICANTS RELATED TO THE RESPONDENT BY BLOOD OR MARRIAGE Your Full Name _________________________________________________________________ Address ________________________________________________________________________ City/State/Zip _____________________________________Phone _____________________ Social Security No. ______________________________ Married (Y/N)___________ ____ Your relationship to the Respondent________________________________________________ is Name and address of your spouse or nearest relative ______________________________________ _____________________________________________________________________________________ Name, address and age of your dependent children and relationship of any other dependents you are supporting ____________________________________________________________________________ Name and address of current employer ________________________________________________ __________________________________________________ Monthly net pay ______________________ Name and address of spouss ce urrent employer _________________________________________ __________________________________________________ Monthly net pay ______________________ List all other sources of income besides employment pay for yourself and your spouse _________ _____________________________________________________________________________________ List address and value of real estate owned by you or your spouse _________________________ _____________________________________________________________________________________ List automobiles and other vehicles owned by you or your spouse _________________________ _____________________________________________________________________________________ List balance and name of bank for any bank accounts owned by you or your spouse ___________ _____________________________________________________________________________________ List cash not in bank or held by others _______________________________________________ _____________________________________________________________________________________ List all other property or assets owned by you or your spouse with their value (example - stocks, bonds, jewelry, furniture, etc) _____________________________________________________________ _____________________________________________________________________________________ List amount and name of debtor for money owed to you or your spouse by others _____________ _____________________________________________________________________________________ The nature and amount of the expenses of the Applicant are:______________________________ _____________________________________________________________________________________ =========================================================================== NOTE TO ALL APPLICANTS: Attach a copy of the letter or form from the referring agency confirming payment authorization. The above information is true and I ask the Court to use this information to determine whether this casecan be approved for payment from the Marion County Indigent Guardianship Fund and/or waiver of court fees and costs. _______________________________________ Signature of Affiant SUBSCRIBED AND SWORN TO before me thi

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