Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR For Clerk's Use Only Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Case Number: Name of Petitioner/Plaintiff SUPPLEMENTAL APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS Name of Respondent/Defendant STATE OF ARIZONA COUNTY OF ) ) ss Notice. A Fee Deferral is only a temporary postponement of the payment of the fees due. You may be required to make payments depending on your income. A Fee Waiver is usually permanent unless your financial circumstances change during the pendency of this court action. I am requesting a deferral/waiver of any unpaid fees and/or costs in my case. I understand that if I request deferral or waiver because I am a participant in a government assistance program, I am required to provide proof at the time of filing. The document(s) submitted must show my name as the recipient of the benefit and the name of the agency awarding the benefit. Note. All other applicants must complete the financial questionnaire beginning at section 3. If you are a participant in one of the programs in section 1 or 2 (below), you do not need to complete the financial questionnaire, and can proceed to the signature page. 1. [ ] DEFERRAL: I receive government assistance from the state or federal program marked below or am represented by a not for profit legal aid program: [ ] Temporary Assistance to Needy Families (TANF) [ ] Food Stamps [ ] Legal Aid Services 2. [ ] WAIVER: [ ] I receive government assistance from the federal Supplemental Security Income (SSI) program. 3. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES. List all persons you support (including those you pay child support and/or spousal maintenance/support for): © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED SWD GNF92f - 020515 Use current version Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: _______________ NAME RELATIONSHIP STATEMENT OF INCOME AND EXPENSES Employer name: Employer phone number: [ ] I am unemployed (explain): My prior year's gross income: MONTHLY INCOME My total monthly gross income: $ My spouse's monthly gross income (if available to me): $ Other current monthly income, including spousal maintenance/support, retirement, rental, interest, pensions, and lottery winnings: $ TOTAL MONTHLY INCOME MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: Rent/Mortgage payment Car payment Credit card payments Explain: Other payments & debts Household Utilities/Telephone/Cable Medical/Dental/Drugs Health insurance Nursing care Tuition Child support Child care Spousal maintenance Car insurance Transportation Other expenses (explain) PAYMENT AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ LOAN BALANCE $ $ $ $ $ $ TOTAL MONTHLY EXPENSES $ STATEMENT OF ASSETS: List only those assets available to you and accessible without financial penalty. ESTIMATED VALUE Cash and bank accounts $ Credit union accounts $ Other liquid assets $ TOTAL ASSETS $ © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED SWD Page 2 of 3 GNF92f - 020515 Use current version American LegalNet, Inc. www.FormsWorkFlow.com Case Number: _______________ THE BASIS FOR THE REQUEST IS: 4. [ ] DEFERRAL: A. [ ] My income is insufficient or is barely sufficient to meet the daily essentials of life, and includes no allotment that could be budgeted for the fees and costs that are required to gain access to the court. My gross income as computed on a monthly basis is 150% or less of the current federal poverty level. (Note: Gross monthly income includes your share of community property income if available to you.) OR B. [ ] I do not have the money to pay court filing fees and/or costs now. I can pay the filing fees and/or costs at a later date. Explain. OR C. [ ] My income is greater than 150% of the poverty level, but have proof of extraordinary expenses (including medical expenses and costs of care for elderly or disabled family members) or other expenses that reduce my gross monthly income to 150% or below the poverty level. DESCRIPTION OF EXPENSES AMOUNT $ $ $ $ TOTAL EXTRAORDINARY EXPENSES 5. [ ] WAIVER: I am permanently unable to pay. My income and liquid assets are insufficient or barely sufficient to meet the daily essentials of life and are unlikely to change in the foreseeable future. OATH OR AFFIRMATION I declare under penalty of perjury that the foregoing is true and correct. Date Signature Applicant's Printed Name Date My Commission Expires/Seal: Deputy Clerk or Notary Public © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED SWD Page 3 of 3 GNF92f - 020515 Use current version American LegalNet, Inc. www.FormsWorkFlow.com