Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Self (Without an Attorney) OR Representing Attorney for Petitioner Respondent FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Case Number: Name of Petitioner/Plaintiff APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS AND CONSENT TO ENTRY OF JUDGMENT Name of Respondent/Defendant STATE OF ARIZONA ) COUNTY OF MARICOPA ) 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. Addition 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. © Superior Court of Arizona in Maricopa County June 17, 2010 ALL RIGHTS RESERVED ADW GNF11f Page 1 of 5 Use current form American LegalNet, Inc. www.FormsWorkFlow.com The basis for the request is: 1. DEFERRAL: A. I receive governmental assistance from the state/federal program(s) marked below: Temporary Assistance to Needy Families (TANF) Food Stamps Represented by Community Legal Services 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. B. C. 2. A. B. 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. 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. 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 that follows. 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. © Superior Court of Arizona in Maricopa County June 17, 2010 ALL RIGHTS RESERVED ADW GNF11f Page 2 of 5 Use current form American LegalNet, Inc. www.FormsWorkFlow.com 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 ASSISTANCE: I receive assistance from: Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTCS) Other: (Explain/Describe) EMPLOYER INFORMATION Employer Name: Employer Address: Employed since: (Month and Year you started) 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 June 17, 2010 ALL RIGHTS RESERVED ADW $ $ GNF11f Page 3 of 5 Use current form American LegalNet, Inc. www.FormsWorkFlow.com My monthly expenses and debts are: A Rent/Mortgage payment Car Payment Car Payment Credit Card Payments Credit Card Payments B MONTHLY PAYMENTS LOAN BALANCE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Other Financing Obligations with Monthly Payments: Describe: 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 Contributions to Retirement Plan / Account 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. * ESTIMATED VALUE $ $ $ $ $ Cash and Bank Accounts Credit Union Accounts Retirement Accounts Other, including Stocks & Bonds Other Equity* in: 1. Home 2. Cars/ Other Vehicles 3. Other Property $ $ $ TOTAL ASSETS: (Add) $ * Equity is defined as market value minus any liens or loans. © Superior Court of Arizona in Maricopa County June 17, 2010 ALL RIGHTS RESERVED ADW GNF11f Page 4 of 5 Use current form American LegalNet, Inc. www.FormsWorkFlow.com EXTRAORDINARY EXPENSES: For example: unusual medical needs, financial hardship, costs of care of elderly or disabled family members. (Proof must be submitted.) AMOUNT $ $ $ DESCRIPTION TOTAL EXTRAORDINARY EXPENSES (Add) $ 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 calendar days after entry of final judgment. If your case is dismissed for any reason, the fees and costs are still due. CONSENT TO ENTRY OF JUDGMENT: By signing this Application, I agree that a judgment may be entered against me for all fees and/or costs that are deferred but remain unpaid after thirty (30) calendar days after entry of final judgment. Judgment may be entered against me unless any one of the following applies: A. B. C. D. E. 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/or 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/or costs that remain unpaid in the lower court shall not be entered until after the appeals process is concluded. OATH OR AFFIRMATION The contents of this document are true and correct to the best of my knowledge and belief. Date Signature Printed Name Date Signed or Affirmed Judicial Officer, Deputy Clerk or Notary Public My Commision Expires/Seal: © Superior Court of Arizona in Maricopa County June 17, 2010 ALL RIGHTS RESERVED ADW GNF11f Page 5 of 5 Use current form American LegalNet, Inc. www.FormsWorkFlow.com