Affidavit In Support Of Marion County Indigent Guardianship Fund Application And Or Motion To Waive Fees And Costs
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1
2IN THE CIRCUIT COURT OF THE STATE OF OREGON
THIRD JUDICIAL DISTRICT
Probate Department
In the Matter of the Guardianship of:
)
Case No.
)
)
AFFIDAVIT IN SUPPORT OF MARION
__________________________________
)
COUNTY INDIGENT GUARDIANSHIP
Respondent.
)
FUND APPLICATION AND/OR MOTION TO
)
WAIVE FEES AND COSTS
STATE OF OREGON
)
)
ss.
County of _______________ )
I hereby swear or affirm that I am or intend to be the Petitioner in the above matter and provide the
Court the following information:
1.
The Respondent has no or insufficient financial resources which could be utilized to pay for
the 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 financial
resources 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 compensation
guidelines for the Marion County Indigent Guardianship Fund.
SECTION A - TO BE COMPLETED BY ALL APPLICANTS
1. The source and amount of Respondent’s income is: ________________________________________
____________________________________________________________________________________
2. Respondent’s assets are (list type and value and include bank accounts, funds held by others, real
estate, autos, stocks, etc.): ______________________________________________________________
____________________________________________________________________________________
3. The nature and amount of Respondent’s expenses are: _____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Describe the Respondent’s current medical, physical and/or mental condition which necessitates the
appointment of a Guardian: _____________________________________________________________
____________________________________________________________________________________
5. Describe what other efforts have been made to obtain guardianship or other medical decision making
authority for the Respondent: ____________________________________________________________
____________________________________________________________________________________
6. Describe what other efforts have been made to get funds to pay for the costs of obtaining a
guardianship for the Respondent: ________________________________________________________
____________________________________________________________________________________
7. Is the Respondent a client of Senior Services, Mental Health, Disability Services, or other State,
County, or local agency?
Yes
No If yes, which agency? ________________________________
AFFIDAVIT IN SUPPORT OF MARION COUNTY INDIGENT GUARDIANSHIP FUND APPLICATION AND/OR
MOT ION TO W AIV E FEE AN D C OS TS - Page 1 of 2
FC (10/20/04)
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