Entire Packet 10

INSTRUCTIONS FOR FEE DEFERRAL
OR WAIVER APPLICATION & DECLARATION
Fees and costs are required in most civil cases. A list of fees is available at
www.courts.oregon.gov or from the court clerk. You may ask the court to defer or waive those
fees and costs. The court can only defer or waive fees if you are low-income (according to federal
poverty guidelines). Any deferral or waiver granted is valid only for the specified fees and only
for the case number on your application.
Complete the Application for Deferral or Waiver of Fees & Declaration in Support, as well as
an Order Regarding Deferral or Waiver of Fees. Complete the information about the case and
the fee you want deferred or waived on the Order but DO NOT mark anything below “The court
finds Applicant:” Be sure to fill in the county name at the top of the page.
The case heading must be the same as on the papers you filed or received in the case you’re
filing in (party names and case number if available)
The Application and Declaration form is confidential – only the court can see it
The court may do one of four things:
1) Order your fees waived. You do not have to pay the fee unless the court makes a
different order later in the case.
2) Order you to pay the fees but defer when payment is due. You may be placed on
a payment plan. Additional costs for administration and collection may be added to
your fee amount.
3) Postpone ruling on your application. The court will not put you on a payment
plan and will not add additional costs. The court will review your case information at
a later date and at that time may deny your application, waive your fee, or order you
to pay the fee but defer when payment is due. If payment is ordered but deferred, the
court may place you on a payment plan with additional costs and fees added for
administration and collection.
4) Deny your application and order you to pay the fees
A judgment against you will be entered for any fees you are ordered to pay. The judgment will be
on behalf of the State of Oregon and may include additional costs and fees.
At the end of your case, the court may review any earlier rulings regarding fees and make
changes based on your status at the time and the result of the case.
You will receive a Notice of Entry of Judgment that will include the total amount due
Fees are payable to the State of Oregon, but payment must be made to the circuit court where
your case was filed. The court accepts cash, credit and debit cards, and money orders or checks
made out to the State of Oregon.
Fee Deferral or Waiver Application and Declaration OJD OFFICIAL

Page 1 of 1 (Feb 2022)
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF
Case No.
Plaintiff/Petitioner
v. APPLICATION FOR DEFERRAL
OR WAIVER OF FEES
& DECLARATION IN SUPPORT
Defendant/Respondent
Applicant’s Full Name:

First Middle Last
ACCESS TO THIS DOCUMENT IS RESTRICTED TO PROTECT THE PRIVACY OF PARTIES
I am the plaintiff/petitioner defendant/respondent other:
I am unable to pay the following right now:

Filing fee for Petition/Complaint/Claim Response/Answer Motion or
(name of document):
Settlement conference, arbitration, or trial fee
Sheriff’s service fee (explain why you cannot find another person to serve papers. Service
can be done by any competent person who is at least 18 years old, a resident of Oregon (or the state
where service is made), and who is not a party to the case or a party’s lawyer, employee, officer, or
director)
1. I understand that an Application for Deferral or Waiver of Fees can defer or waive only one
fee at a time except for the sheriff’s service fee. I understand that I must complete a separate
Application for each fee that I want the court to defer or waive.
2. If fees are not waived, I understand that payment is a debt to the state of Oregon. Additional
fees may be added for administrative and collection costs.
3. I understand that if the clerk denies my application I have the right to ask a judge to review
my application
4. Any waiver or deferral I am granted during the case may be revoked in full or in part at the
end of the case based on the final outcome
Fee Deferral or Waiver Application OJD OFFICIAL

Declaration
1. PERSONAL
Date of Birth (month/day/ year)
*SSN: Driver License/State ID:
*I am providing my Social Security number voluntarily. I understand that I cannot be forced to provide it or
be denied consideration solely for failure to provide it. It may be used to verify my identification, employment
information, and for collection of fees.
Number of people living in your household:
2. LEGAL AID
Are you represented in this case by a legal aid attorney?
No
Yes (Name):
3. PUBLIC ASSISTANCE
Check any programs you currently receive assistance from:
(include the amount you receive PER MONTH)
Food Stamps (SNAP-Supplemental Nutrition Assistance Program) - $
Supplemental Security Income (SSI) - $
Temporary Assistance to Needy Families (TANF) - $
Oregon Health Plan (OHP)
 Total monthly benefits received:$
Complete sections 4 – 7 with amounts for all members of your household combined
4. EMPLOYMENT AND INCOME

 Total monthly income from all jobs, before taxes are taken out: $
 Total monthly income from other sources: $

(including annuities, settlement income, and any other source of funds or support)
TOTAL INCOME FROM ALL SOURCES: $
5. ASSETS
Total cash available from all accounts: $ (cash, checking account, savings, etc.)
List any assets you have including vehicles, real estate, boats, guns, jewelry, livestock, business
interests, etc.:
Value of assets:
TOTAL VALUE OF ALL ASSETS & CASH: $

6. LIVING EXPENSES (per month)
 Home: $
(Rent, mortgage, utilities, cell phone, food)
 Transportation: $
(parking, gas, bus, insurance, vehicle loan payments)
 Other: $
(student loans, day care, court fines, medical, child support, credit cards, etc.)
TOTAL MONTHLY LIVING EXPENSES: $
7. OTHER INFORMATION YOU WANT COURT TO CONSIDER
I hereby declare that the above statements are true to the best of my
knowledge and belief. I understand they are made for use as evidence in
court and I am subject to penalty for perjury.
Date Signature
Name (printed)
Contact Address City, State, ZIP Contact Phone

IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF
Case No. ___________________

Plaintiff/Petitioner
v. ORDER RE: DEFERRAL OR
WAIVER OF FEES
Defendant/Respondent
The court reviewed the Application for Deferral or Waiver of Fees and Declaration in Support
for (Applicant Name):
regarding the following fees:
Filing Fee Sheriff’s service fee Motion Fee

Arbitration Fee Trial Fee
Other: (describe)
The court finds Applicant:

DOES qualify for a deferral or waiver of fees
DOES NOT qualify for a deferral or waiver of fees
Additional findings:
The court orders:

Determination of fee obligation is postponed at this time. No payment is due from the
applicant until further order of the court.
Fees are deferred for full payment. Payment must be made according to the terms of the
attached payment plan (or) $ per month until paid in full
A judgment will be entered against Applicant. Collection costs may be added without
further notice if fees are not paid as ordered.
Fees are waived. The court may change or revoke this waiver at a later time.
Application is denied
Application is granted in part:
Court Signature:
Fee Deferral or Waiver Order OJD OFFICIAL

Certificate of Readiness
This proposed order is ready for judicial signature because service is not required under UTCR 5.100
because this order is submitted ex parte as allowed by statute or rule
Submitted by: plaintiff/petitioner defendant/respondent other:
Signature Print Name
I understand that I am subject to penalty for perjury for giving false information to the court. I
believe all factual information in this Order is true. I understand that this Order is enforceable
by the court.
Date Signature
Name (printed)
Contact Address City, State, ZIP Contact Phone
Fee Deferral or Waiver Order OJD OFFICIAL


Entire Packet 10

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Entire Packet 10

Uploaded by

Copyright:

Available Formats

INSTRUCTIONS FOR FEE DEFERRAL

OR WAIVER APPLICATION & DECLARATION

The court may do one of four things:

Fee Deferral or Waiver Application and Declaration OJD OFFICIAL

Applicant’s Full Name:

ACCESS TO THIS DOCUMENT IS RESTRICTED TO PROTECT THE PRIVACY OF PARTIES

I am the plaintiff/petitioner defendant/respondent other:

I am unable to pay the following right now:

Fee Deferral or Waiver Application OJD OFFICIAL

Number of people living in your household:

 Total monthly benefits received:$

4. EMPLOYMENT AND INCOME

 Total monthly income from other sources: $

TOTAL INCOME FROM ALL SOURCES: $

TOTAL VALUE OF ALL ASSETS & CASH: $

Fee Deferral or Waiver Application OJD OFFICIAL

TOTAL MONTHLY LIVING EXPENSES: $

7. OTHER INFORMATION YOU WANT COURT TO CONSIDER

Contact Address City, State, ZIP Contact Phone

Fee Deferral or Waiver Application OJD OFFICIAL

Case No. ___________________

Filing Fee Sheriff’s service fee Motion Fee

The court finds Applicant:

The court orders:

Application is granted in part:

Fee Deferral or Waiver Order OJD OFFICIAL

Submitted by: plaintiff/petitioner defendant/respondent other:

Signature Print Name

Contact Address City, State, ZIP Contact Phone

Fee Deferral or Waiver Order OJD OFFICIAL

You might also like