Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY ______________________________________ Case No. _________________ Petitioner and APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS AND CONSENT TO ENTRY OF JUDGMENT ______________________________________ Respondent IMPORTANT: This Application for deferral of court fees and/or costs includes a Consent to Entry of Judgment. By signing this Consent, you agree that a judgment may be entered against you for all fees and/or costs that are deferred, but that remain unpaid after thirty (30) calendar days following the entry of final judgment. At the conclusion of the case you will receive a Notice indicating how much is owed and what steps you must take to avoid a judgment against you if you are still unable to pay. Additional details about this process are discussed in the Judgment Section of this Application. STATE OF ARIZONA COUNTY OF PIMA ) )ss ) STATEMENTS MADE TO THE COURT UNDER OATH. I swear or affirm that the information in this application is true and correct. I make this statement under penalty of prosecution for perjury if it is determined that I did not tell the truth. I am requesting a deferral or waiver of the following fees and/or costs in my case: † Any or all of the following: All filing fees, fees for issuance of summonses and subpoenas, fees for obtaining one certified copy of a temporary order in a domestic relations case, a final order, judgment or decree in all civil proceedings, child support payment history and fees for attending the Domestic Relations Education on Children’s Issues Program, pursuant to A.R.S. § 25-355. † Fees for service of process by a sheriff, marshal, constable or local law enforcement agency (fill out separate affidavit form). † Fees for service by publication (fill out separate affidavit form). † Filing fees and photocopy fees for preparation of the record on appeal. † Court reporter’s fees of reporters or transcribers employed by the court for the preparation of the transcript. 1 deferral-application for deferral/waiver consent to judgment.form Revised 02.11.11 American LegalNet, Inc. www.FormsWorkFlow.com The basis for this request is: † 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 unlikely to change in the foreseeable future. † DEFERRAL: The basis for the deferral request is that I receive governmental assistance from the state/federal program(s) checked below: † Temporary Assistance to Needy Families (TANF) † Food Stamps (Qwest Card) † Supplemental Security Income (SSI) for disabilities † General Assistance (GA) IF YOU CHECKED ONE OF THE BOXES ABOVE (Wavier or Deferral), you must complete the Financial Questionnaire. You must sign this application in front of the court clerk or a notary public, if submitted by mail or a third party. You must also submit proof that you receive governmental assistance. If you are submitting this application by mail or a third party, you must attach a photocopy of that proof. OR The basis for the deferral or waiver request is: † My income is insufficient or 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. You must fill out the Financial Questionnaire below. To determine whether income is insufficient or barely sufficient, the court will review your income and expenses. Among the factors the court may consider are: 1. Whether your gross income as computed on a monthly basis is 150% or less of the current federal poverty level. (To see if you qualify, a table showing 150% of the poverty levels by family size is attached.) Gross monthly income includes your share of community property income if available to you. 2. If your income exceeds 150% of the poverty level, but you have proof of extraordinary expenses, including medical expenses, costs of care for elderly or disabled family members or other expenses that the court finds are extraordinary and that reduce your gross monthly income to 150% of the poverty level or below. OR IF NONE OF THE ABOVE REASONS APPLY, you still may request a deferral or waiver of court fees and/or costs for good cause shown. If granted, the court either will postpone payment until the conclusion of the case or establish a schedule for you to make payments. The basis for the deferral or waiver request is: † 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. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ You must fill out the Financial Questionnaire (see next page). 2 deferral-application for deferral/waiver consent to judgment.form Revised 02.11.11 American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List the individuals who you support (including paying child support and/or spousal maintenance): NAME RELATIONSHIP _________________________________________ _______________________________________ _________________________________________ _______________________________________ _________________________________________ _______________________________________ STATEMENT OF INCOME AND EXPENSES ASSISTANCE: I receive assistance from: † Arizona Health Care Cost Containment System (AHCCCS) † Arizona Long Term Care System (ALTCS) † Other (explain): _______________________________________ _____________________________________________________ MONTHLY INCOME: Employer’s name: __________________________________________________ Employer’s address: __________________________________________________ Employed since (month/year): ____________________ Monthly gross income: $____________ Other current monthly income, including spousal maintenance, retirement, rental, interest, pensions, scholarships, grants, royalties, lottery winnings (explain amount and source): $ ___________ My spouse’s monthly gross income (if available to me): $____________ TOTAL MONTHLY INCOME: $___________ 3 deferral-application for deferral/waiver consent to judgment.form Revised 02.11.11 American LegalNet, Inc. www.FormsWorkFlow.com MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: PAYMENT AMOUNT LOAN BALANCE Rent/Mortgage Payment $ $______________ Car Payment $ $______________ Credit Card Payments $ $______________ $ $______________ Explain: Other Payments & Debts: Explain: Food/Household Supplies $ Utilities/Telephone $ Clothing $ Medical/Dental/Drugs $ Health Insurance $ Nursing Care $ Laundry $ Child Support $ Child Care $ Spousal Maintenance actually paid $ Car Insurance $ Gasoline/Bus Fare $ Contributions to Employer or Other Retirement Account $ TOTAL MONTHLY PAYMENTS $_____________ STATEMENT OF ASSETS: Equity is defined as market value minus any liens or loans. List only those assets available to you and are accessible without financial penalty. ESTIMATED VALUE Cash & Bank Accounts $____________________ Credit Union Accounts $____________________ Equity in: 1. Home $____________________ 2. Other Property $____________________ 3. Cars/Other Vehicles $____________________ Retirement Accounts $____________________ Other, including stocks, bonds, etc. $____________________ TOTAL ASSETS: $______________ 4 deferral-application for deferral/waiver consent to judgment.form Revised 02.11.11 American LegalNet, Inc. www.FormsWorkFlow.com EXTRAORDINARY EXPENSES: Other facts that support this application are: (For example, describe and provide proof of unusual medical needs, financial hardship, costs of care of elderly or disabled family members) DESCRIPTION AMOUNT $________________ $________________ TOTAL EXTRAORDINARY EXPENSES 5. $______________ CONSENT TO JUDGMENT: By signing this application, you agree that a judgment may be entered against you for all fees and/or costs not taxed to another party that are deferred, but that remain unpaid after thirty (30) calendar days following entry of final judgment. Judgment automatically will be entered against you unless any one of the following applies: A. Fees and costs are taxed to another party; B. You make a supplemental application for waiver or further deferral of fees and/or costs and a decision by the court is pending; C. The court orders that the fees and costs be waived or further deferred; or D. Within twenty (20) days of the date the court denies the supplemental application, you either: 1. Pay the fees and/or costs; or 2. Request a hearing on the court’s order denying waiver or further deferral. If you request a hearing, the court cannot enter the consent judgment unless a hearing is held, waiver or further deferral is denied and payment has not been made within the time prescribed by the court. At the end of your case, you will receive a notice reminding you that you may submit a supplemental application for further deferral or waiver if you believe you still cannot afford to pay your court fees and/or costs. The court will decide at that time whether or not you must pay. ACKNOWLEDGMENT AND SIGNATURE UNDER OATH Today’s Date: Signature: ____________________________________ Print Your name:_______________________________ SUBSCRIBED AND SWORN or affirmed and acknowledged before me on (date) ___________________ By___________________________________________ My Commission Expires: _____________________________________________ Judicial Officer, Clerk or Notary Public 5 deferral-application for deferral/waiver consent to judgment.form Revised 02.11.11 American LegalNet, Inc. www.FormsWorkFlow.com