(COURT'S JURISDICTIONAL NAME AND ADDRESS HERE) Case Number: APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS AND CONSENT TO ENTRY OF JUDGMENT Name of Petitioner/Plaintiff Name of Respondent/Defendant STATE OF ARIZONA COUNTY OF ) ) ss. IMPORTANT This "Application for Deferral or Waiver of Court Fees and/or Costs" includes a "Consent to Entry of Judgment." By signing this Consent, you agree a judgment may be entered against you for all fees and costs that are deferred but remain unpaid thirty (30) calendar days after entry of final judgment. At the conclusion of the case you will receive a Notice of Court Fees and Costs Due indicating how much is owed and what step 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 "Consent to Entry of Judgment" section of this application. STATEMENTS MADE TO THE COURT UNDER OATH OR AFFIRMATION. I swear or affirm that the information in this application is true and correct. I make this statement under the penalty of prosecution for perjury if it is determined that I did not tell the truth. I am requesting a deferral/waiver of the following fees and/or costs in my case: [] Any or all of the following: All filing fees, fees for the issuance of either a summons and subpoena, or fees for obtaining one certified copy of a temporary order in a domestic relations case or a final order, judgment or decree in all civil proceedings. 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 the preparation of the record on appeal. Court reporter's fees of reporters or transcribers employed by the court for the preparation of the transcript. [] [] [] [] The basis for the request is: 1. A. [ ] DEFERRAL: [] I receive governmental assistance from the state/federal program(s) marked below: [ ] Temporary Assistance to Needy Families (TANF) [ ] Food Stamps OR 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. NOTE: To determine whether income is insufficient or barely sufficient, the court will review your B. [] Page 1 of 4 Revised December 2010 American LegalNet, Inc. www.FormsWorkFlow.com C. [] 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. Gross monthly income includes your share of community property income if available to you. 2. If your income is greater than 150% of the poverty level, but you have proof of extraordinary expenses (including medical expenses and costs of care for elderly or disabled family members) or other expenses that the court finds are extraordinary that reduce your gross monthly income to at or below 150% of the poverty level. OR 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. 2. A. B. [ ] 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. I receive government assistance from the federal program Supplemental Security Income (SSI). NOTE: Every applicant, regardless of his or her financial circumstances, must complete the Financial Questionnaire (below). If you submit the Application and Financial Questionnaire in person, you MUST sign it in front of the court clerk; if you submit the form by mail or by a third party, you MUST sign it in front of a notary public. You must submit proof that you receive governmental assistance. If you submit the Application and Financial Questionnaire by mail or by a third party, please attach a copy of your proof of governmental assistance. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support and/or spousal maintenance/support for): 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: My monthly income is: Monthly gross income: Employer name: Employer address: Employed since (month/year): Other current monthly income, including spousal maintenance/support, retirement, rental, interest, pensions, scholarships, grants, royalties, lottery winnings (explain amount and source): $ $ My spouse's monthly gross income (if available to me): $ Page 2 of 4 Revised December 2010 American LegalNet, Inc. www.FormsWorkFlow.com TOTAL MONTHLY INCOME $ 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 $ Food/Household supplies $ Utilities/Telephone $ Clothing $ Medical/Dental/Drugs $ Health Insurance $ Nursing care $ Laundry $ Child Support $ Child Care $ Spousal Maintenance $ Car Insurance $ Gasoline/Bus Fare $ Contributions to Employer or Other Retirement Account $ TOTAL MONTHLY PAYMENTS $ STATEMENT OF ASSETS: List only those assets available to you and accessible without financial penalty. Equity is defined as market value minus any liens or loans. ESTIMATED VALUE Cash and Bank Accounts $ Credit Union Accounts $ Equity in: 1. Home $ 2. Other property $ 3. Cars/other vehicles $ 4. Other, including stocks, bonds, etc. $ 5. Retirement accounts $ TOTAL ASSETS $ EXTRAORDINARY EXPENSES: For example, unusual medical needs, financial hardship, costs of care of elderly or disabled family members. (Proof must be submitted.) DESCRIPTION AMOUNT $ $ $ TOTAL EXTRAORDINARY EXPENSES $ Page 3 of 4 Revised December 2010 American LegalNet, Inc. www.FormsWorkFlow.com Note: If you receive a deferral and have unpaid fees at the end of your case you will receive a Notice of Court Fees and Costs Due. This is to remind you that you may submit a supplemental application for further deferral or waiver if you believe you need more time to pay or cannot afford to pay your court fees and costs. The court will decide at that time whether or not you must pay. If you do not file a supplemental applicat