Deferred Fee Application Information
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Deferred Fee Application Information Form. This is a Arizona form and can be use in Maricopa Local County.
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Tags: Deferred Fee Application Information, Arizona Local County, Maricopa
CASE NUMBER:
Plaintiff/Petitioner
APPLICANT
Complete all
information
in this
section.
DATE:
Defendant/Respondent
DEFERRED FEE APPLICATION INFORMATION
NAME:
ADDRESS:
CITY:
STATE:
SSN:
ZIP CODE:
PHONE(H):
(
)
PHONE (W):
DO YOU HAVE AN ATTORNEY?
YES
)
PHONE (Cell):
NO
(
(
)
(FOR COURT USE ONLY: Do Not Write in this Section (except for your signature, below).
FINANCIAL STATUS OF A DEFERRED FEE
Special
Commissioner
Complete all
information
for each
deferred fee
in this section.
FEE CODE #
TYPE
$
FEE CODE #
TYPE
$
FEE CODE #
TYPE
$
TOTAL AMOUNT OF FEES THAT HAVE BEEN DEFERRED: $
AMOUNT OF PARTIAL PAYMENT PAID AT TIME OF FILING: $
BALANCE: $
Special
Commissioner
BALANCE OF DEFERRED FEE(S) DUE ON
DAY OF
, 20
Complete this
section if a
payment plan
is set up.
FINAL PAYMENT IS DUE ON OR BEFORE (BUT NO LATER THAN) THE DUE DATE ABOVE.
Cross out if
deferred until
further notice.
ANY BALANCE LEFT OUTSTANDING AFTER THE DUE DATE WILL BE SENT TO A COLLECTIONS
AGENCY.
I (APPLICANT) SHALL MAKE (
Applicant:
Special
Commissioner
Check why
deferred until
further notice.
WEEKLY
MONTHLY) PAYMENTS OF $
APPLICANT SIGNATURE:
(FOR COURT USE ONLY: Do Not Write in this Section (except for your signature, below).
ASSISTANCE RECEIVED/ INCOME INFORMATION
TANF (TEMPORARY ASSISTANCE TO NEEDY FAMILIES)
SSI
FOOD STAMPS
< 150%
COMMUNITY LEGAL SERVICES
Applicant:
APPLICANT SIGNATURE:
February 2, 2011
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GNF10f
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