Name: Mailing Address: City, State, Zip: Phone Number: Representing Self SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO Case Number: Name of Petitioner/Plaintiff APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND COSTS AND CONSENT TO ENTRY OF JUDGMENT Name of Respondent/Defendant IMPORTANT This Application for Deferral of Court Fees and 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 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 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 Consent to Entry of Judgment Section of this Application. State of Arizona County of ) ) 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 the 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 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 law enforcement (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. Page 1 of 5 Revised March 2009 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com The basis for the request is: 1. [] 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. 2. [] [] DEFERRAL: a. I receive governmental assistance from the state/federal program(s) checked below: [] Temporary Assistance to Needy Families (TANF) [] Food Stamps [] Supplemental Security Income (SSI) for disabilities [] General Assistance (GA) If you checked either boxes 1 or 2a., 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 [] b. 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 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. Although 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 [] c. Page 2 of 5 Revised March 2009 I do not have the money to pay court filing fees and costs now. I can pay the filing fees and/or costs at a later date. Explain. Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com If you checked either boxes 2b. or 2c., 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. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List the persons you support (including paying child support and 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: My monthly income is: Monthly gross income: Employer name: Employer address: Employed since (month/year): Other current monthly income, including spousal maintenance, retirement, rental, interest, pensions, dividends, scholarships, grants, royalties, lottery winnings (explain amount and source): My spouse's monthly gross income (if available to me): 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 $ Food/Household Supplies $ $ $ Utilities/Telephone $ Clothing $ $ $ Medical/Dental/Drugs $ Page 3 of 5 Revised March 2009 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com Payment Amount 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: Loan Balance $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 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. Cash and Bank Accounts $ Credit Union Accounts $ Equity in: $ 1. Home 2. Other Property $ 3. Cars/Other Vehicles $ Other, including Stocks, Bonds, etc. $ 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 $ 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 application, the original deferral order remains in effect and a consent judgment may be entered against you if you do not pay within thirty (30) calendar days after entry of final judgment. If your case is dismissed for any reason, the fees and costs are still due. Page 4 of 5 Revised March 2009 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com CONSENT TO ENTRY OF JUDGMENT: By signing this Application, I agree that a judgment may be entered against me for all fees and costs that are deferred but that remain unpaid thirty (30) calendar days after entry of final judgment. Judgment may be entered against me unless any one of the following applies: A. B. B. C. D. Fees and costs are taxed to another party; I have an established schedule of payments in effect and I am current with those payments; I file a supplemental application for waiver or further deferral of fees and costs and a decision by the court is pending; In response to a supplemental application, the court orders that the fees and costs be waived or further deferred; or Within twenty days of the date the court denies the supplemental application, I either: 1. Pay the fees and costs; or, 2. Request a hearing on the court's order denying waiver or further deferral. If I request a hearing, the court cannot enter the consent judgment unless a hearing is held, further deferral or waiver is denied and payment has not been made within the time prescribed by the court. If you appeal the final decision in your case, a consent judgment for deferred fees and costs that remain unpaid in the lower court shall not be entered until after the appeals process is concluded. ACKNOWLEDGMENT AND SIGNATURE UNDER OATH Sign in front of a notary. Notaries are at the Self-Help Center in the Courthouse and at most banks or listed in the Yellow Pages. The person signing must bring photo ID. Notaries usually charge a fee. Signature: Printed Name: Subscribed and sworn before me this date: by: Seal: Judicial Officer, Clerk or Notary Public Notary Expiration Date: Page 5 of 5 Revised March 2009 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com