Fill and Sign the Affidavit for Deferral of Fees with Emphasis on Expenses Versus Income Oregon Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF ________________ In the Matter of the Marriage of ) ) Case No. _______________ _________________________________, ) Petitioner, ) AFFIDAVIT FOR DEFERRAL OF FEES And ) _________________________________, ) Respondent ) STATE OF OREGON ) ) ss County of__________ ) I swear/affirm that I am the ___ Petitioner ___ Respondent for a Decree of Dissolution and that I am unable to pay necessary fees. I support _____ people. My assets, monthly income and expenses are as follows: MONTHLY EXPENSES Housing $ __________ Utilities $ __________ Telephone $ __________ Affidavit for Deferral of Fees 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Food $ __________ Clothing $ __________ Transportation $ __________ Medical Expenses $ __________ Laundry, cleaning and personal requirements $ __________ Total installment payments $ __________ TOTAL MONTHLY EXPENSES $ __________ INCOME AND ASSETS Total monthly income from all sources: $ __________ Assets: $ __________ Savings: $ __________ ____________________________________ Signature ____________________________________ Print or Type Name SUBSCRIBED AND SWORN TO before me this ____ day of _______________, ______. Affidavit for Deferral of Fees 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ________________________________________________ NOTARY PUBLIC FOR OREGON/COURT CLERK My Commission expires: _______________ Submitted by: __________________________________________ Print Name __________________________________________ Address or Contact Address __________________________________________ City Zip __________________________________________ Telephone Number(s) Affidavit for Deferral of Fees 3