Name of Person Filing: Mailing Address: City, State, and Zip Code: Telephone Number: Representing Self COCONINO COUNTY SUPERIOR COURT Case Number: Name of Petitioner/Plaintiff ORDER REGARDING DEFERRAL OR WAIVER OF COURT FEES AND COSTS AND NOTICE REGARDING CONSENT JUDGMENT Name of Respondent/Defendant THE COURT FINDS that the applicant (print name): 1. OR 2. OR 3. OR 4. OR 5. OR 6. OR 7. [] [] IS NOT ELIGIBLE FOR A DEFERRAL of fees and costs. IS ELIGIBLE FOR A DEFERRAL of fees and costs based on financial eligibility. As required by state law, the applicant has signed a consent to entry of judgment. IS ELIGIBLE FOR A DEFERRAL of fees and costs at the court's discretion (A.R.S. § 12-302(L)). IS ELIGIBLE FOR A DEFERRAL of fees and costs based on good cause shown. As required by state law, the applicant has signed a consent to entry of judgment. IS ELIGIBLE FOR A WAIVER of fees and costs because the applicant is permanently unable to pay. IS ELIGIBLE FOR A WAIVER of fees and costs at the court's discretion (A.R.S. § 12302(L)). IS NOT ELIGIBLE FOR A WAIVER of fees and costs. [] [] [] [] [] Page 1 of 3 Revised May 2015 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com IT IS ORDERED: [] DEFERRAL IS DENIED for the following reason(s): [] The application is incomplete because You are encouraged to submit a complete application. [] The applicant does not meet the financial criteria for deferral because A deferral MUST BE granted if the applicant is receiving public assistance benefits from the Temporary Assistance to Needy Families (TANF) program or Food Stamps; has an income that is insufficient or barely sufficient to meet the daily essentials of life and that includes no allotment that could be budgeted to pay the fees and costs necessary to gain access to the court; or, if the applicant demonstrates other good cause. [] DEFERRAL IS GRANTED for the following fees and costs in this court: [] Any or all filing fees; fees for the issuance of either a summons and subpoena; or the cost of attendance at an educational program required by A.R.S. § 25-352; 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 agency. [] Fees for service by publication. [] Filing fees and photocopy fees for the preparation of the record on appeal. [] Court reporter or transcriber fees if employed by the court for the preparation of the transcript. IF A DEFERRAL IS GRANTED, PLEASE CHECK ONE OF THE FOLLOWING BOXES: [] NO PAYMENTS WILL BE DUE UNTIL FURTHER NOTICE. [] SCHEDULE OF PAYMENTS. The applicant shall pay $ each (week, month etc.) until paid in full, beginning . WAIVER IS DENIED for all fees and costs in this case. WAIVER IS GRANTED for all fees and costs in this case that may be waived under A.R.S. § 12-302(H). [] Any or all filing fees; fees for the issuance of either a summons or subpoena; or the cost of attendance at an educational program required by A.R.S. § 25-352; 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 agency. [] Fees for service by publication. [] Filing fees and photocopy fees for the preparation of the record on appeal. [] Court reporter or transcriber fees if employed by the court for the preparation of the transcript. [] [] Page 2 of 3 Revised May 2015 Arizona Supreme Court RIGHT TO JUDICIAL REVIEW. If the application is denied or a payment schedule is set by a special commissioner, you may request the decision be reviewed by a judicial officer. The request must be made within twenty (20) days of the day the order was mailed or delivered to you. If a schedule of payments has been established, payments shall be suspended until a decision is made after judicial review. Judicial review shall be held as soon as reasonably possible. NOTICE REGARDING CONSENT JUDGMENT. Unless any of the following applies, a consent judgment may be entered against the applicant for all fees and costs that are deferred and remain unpaid thirty (30) days after entry of final judgment: A. Fees and costs are taxed to another party; B. The applicant has an established schedule of payments in effect and is current with those payments; C. The applicant filed a supplemental application for waiver or further deferral of fees and costs and a decision by the court is pending; D. In response to a supplemental application, the court orders that the fees and costs be waived or further deferred; or E. Within twenty (20) days of the date the court denies the supplemental application, the applicant either: 1. Pays the fees and costs; or, 2. Requests a hearing on the court's order denying further deferral or waiver. If the applicant requests 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 an appeal is taken, a consent judgment for deferred fees and costs that remain unpaid in the lower court shall not be entered until thirty (30) days after the appeals process is concluded. The procedures for notice of court fees and costs and for entry of a consent judgment continue to apply. If a consent judgment is signed and the applicant pays the fees and costs in full, the court is required to comply with the provisions of A.R.S. § 33-964(C). DUTY TO REPORT CHANGE IN FINANCIAL CIRCUMSTANCES. An applicant who is granted a deferral or waiver shall promptly notify the court of any change in financial circumstances during the pendency of the case that would affect the applicant's ability to pay court fees and costs. Any time the applicant appears before the court on this case, the court may inquire as to the applicant's financial circumstances. DATED: [ ] Judicial Officer [ ] Special Commissioner Page 3 of 3 Revised May 2015 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com