Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Self or Attorney for Representing FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA MARICOPA COUNTY Case Number: Name of Petitioner/Plaintiff. APPLICATION FOR DEFERRAL OF COURT FEES AND/OR COSTS AND CONSENT TO ENTRY OF JUDGMENT Name of Respondent/Defendant 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 on behalf of the estate under the penalty of prosecution for perjury if it is determined that I did not tell the truth. 1. I am requesting a deferral of the following fees and/or costs in my case: Any or all of the following: All filing fees, fees for the 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 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. Court accountant fees and costs Court investigator fees and costs 2. My interest in this case is (check on box): Petitioner for Appointment of a Guardian/Conservator for an Adult or a Minor Petitioner for Appointment of a Personal Representative for the Estate Creditor filing a Demand for Notice Other (describe): © Superior Court of Arizona in Maricopa County June 21, 2007 ALL RIGHTS RESERVED APD Page 1 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkflow.com Case No. 3. The basis for the deferral request is that I or the Estate/Ward/Protected Person receive governmental assistance from the state/federal program(s) checked below: Temporary Assistance to Needy Families (TANF) Food Stamps Supplemental Security Income (SSI) General Assistance (GA) IF YOU CHECKED ONE OF THE BOXES ABOVE, go directly to the end of the last page and date and sign the Application in front of the clerk or a notary public. You do not need to complete other parts of this form. OR 4. The basis for the deferral request is: My or the Estate/Ward/Protected Person’s 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. You must fill out the Financial Questionnaire below. A. 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 at or below 150% of the poverty level. OR IF NONE OF THE ABOVE REASONS APPLY, you still may request a deferral 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. B. I or the Estate/Ward/Protected Person 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 following Financial Questionnaire. © Superior Court of Arizona in Maricopa County June 21, 2007 ALL RIGHTS RESERVED APD Page 2 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkflow.com Case No. 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: My monthly income is: Employer name: Employer 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:$ MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: Rent/Mortgage payment Car Payment Credit Card Payments Explain: Other payments & debts Explain: Food/Household supplies Utilities/Telephone Clothing Medical/Dental/Drugs Health Insurance © Superior Court of Arizona in Maricopa County June 21, 2007 ALL RIGHTS RESERVED APD PAYMENT AMOUNT $ $ $ LOAN BALANCE $ $ $ $ $ $ $ $ $ $ Page 3 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkflow.com Case No. 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: Equity is defined as market value minus any liens or loans. List only those assets available to you and accessible without financial penalty. 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: $ ESTIMATED VALUE $ $ $ $ $ $ $ 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 $ 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 the entry of final judgment. Judgment automatically will be entered against you unless any one of the following applies: A. B. C. D. Fees and costs are taxed to another party; You make a supplemental application for waiver or further deferral of fees and/or costs and a decision by the court is pending; 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, you either: 1. 2. Pay the fees and/or costs; or, Request a hearing on the court’s order denying waiver or further deferral. If you request a hearing, the court can not 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. © Superior Court of Arizona in Maricopa County June 21, 2007 ALL RIGHTS RESERVED APD Page 4 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkflow.com Case No. 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 © Superior Court of Arizona in Maricopa County June 21, 2007 ALL RIGHTS RESERVED APD Page 5 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkflow.com