Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR FOR CLERK'S USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of: Case Number: (or) Name of Petitioner/Plaintiff J Name of Respondent/Defendant STATE OF ARIZONA ) ss APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS AND CONSENT TO ENTRY OF JUDGMENT COUNTY OF MARICOPA ) Notice. A Fee Deferral is only a temporary postponement of the payment of the fees due. You may be required to make payments depending on your income. A Fee Waiver is usually permanent unless your financial circumstances change during the pendency of this court action. I am requesting a deferral or waiver of all fees including: filing a case, issuance of a summons or subpoena, one certified copy of a temporary order in a family law case, one certified copy of the court's final order, preparation of the record on appeal, court reporter's fees of reporters or transcribers, service of process costs, court accountant fees and costs, court investigator fees and costs, and/or service by publication costs. (I have completed the separate Supplemental Information form if I am asking for service of process costs, or service by publication costs.) I understand that if I request deferral or waiver because I am a participant in a government assistance program, I am required to provide proof at the time of filing. The document(s) submitted must show my name as the recipient of the benefit and the name of the agency awarding the benefit. Note. All other applicants must complete the financial questionnaire beginning at section 3. If you are a participant in one of the programs in section 1 or 2 (below), you do not need to complete the financial questionnaire, and can proceed to the signature page. 1. My interest in this case is (check on box): Petitioner for Appointment of a Guardian of a Minor Other (describe): 2. [ ] DEFERRAL: I or the Estate/Ward/Protected Person receive government assistance from the state or federal program marked below or am represented by a not for profit legal aid program: [ ] Temporary Assistance to Needy Families (TANF) [ ] Food Stamps [ ] Legal Aid Services � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED APD Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com JGW11f 090114 Use current form Case No. 3. [ ] WAIVER: [ ] I or the Estate/Ward/Protected Person receive government assistance from the federal Supplemental Security Income (SSI) program. FINANCIAL QUESTIONNAIRE STATEMENT OF INCOME AND EXPENSES: SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support and/or spousal maintenance/support for): NAME RELATIONSHIP EMPLOYER INFORMATION Employer name: Employer phone number: [ ] I am unemployed (explain): My prior year's gross income: $ MONTHLY INCOME INFORMATION Monthly Gross Income: (full amount of wages/salary before any deductions) 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) $ $ TOTAL MONTHLY INCOME: (Add amounts from these lines.) $ � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED APD Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com JGW11f 090114 Use current form Case No. My monthly expenses and debts are: Rent/Mortgage payment Car Payment Credit Card Payments $ $ $ A MONTHLY PAYMENTS $ $ $ $ $ B LOAN BALANCES Other Financing Obligations with Monthly Payments: $ Describe: Describe: $ TOTAL OF LOAN BALANCES: (Add column B) $ Food/Household supplies Clothing Utilities (Electric, Gas, Water, Telephone) Medical / Dental/ Prescription Expenses Health Insurance Car Insurance Gasoline/Bus Fare Spousal Maintenance (alimony paid by you) Child Support Child Care Nursing care Other Other TOTAL MONTHLY PAYMENTS: (Add column A, starting from "Rent/Mortgage" ) $ $ $ $ $ $ $ $ $ $ $ $ $ $ STATEMENT OF ASSETS: List those assets available to you and accessible without financial penalty. Cash and Bank Accounts Credit Union Accounts Other liquid assests ESTIMATED VALUE $ $ $ TOTAL ASSETS: (Add) The basis for the request is: $ 4. [ ] DEFERRAL: A. [ ] 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. My gross income as computed on a monthly basis is 150% or less of the current federal poverty level. (Note: Gross monthly income includes your share of community property income if available to you.) OR � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED APD Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com JGW11f 090114 Use current form Case No. B. [ ] 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. OR C. [ ] My income is greater than 150% of the poverty level, but have proof of extraordinary expenses (including medical expenses and costs of care for elderly or disabled family members) or other expenses that reduce my gross monthly income to 150% or below the poverty level. DESCRIPTION OF EXPENSES AMOUNT $ $ $ TOTAL EXTRAORDINARY EXPENSES $ 5. [ ] 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 are unlikely to change in the foreseeable future. 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. Addition details about this process are discussed in the "Consent to Entry of Judgment" Section of this Application. CONSENT TO ENTRY OF JUDGMENT. By signing this Application, I agree that a judgment may be entered against me for all fees or costs that are deferred but remain u