Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Licensed Fiduciary 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 PB Name of protected (or deceased) person APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND COSTS and CONSENT TO ENTRY of JUDGMENT 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/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): 2. [ ] DEFERRAL: I receive or the Estate/Ward/Protected Person receives 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 [ ] WAIVER: [ ] I receive or the Estate/Ward/Protected Person receives government assistance from the Federal Supplemental Security Income (SSI) program. 3. © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED APD PBW11f-090114 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No. 4. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES. List all persons you support (including those you pay child support and/or spousal maintenance/support for): NAME RELATIONSHIP STATEMENT OF INCOME AND EXPENSES Employer name: Employer phone number: [ ] I am unemployed (explain): My prior year's gross income: MONTHLY INCOME My total monthly gross income: My spouse's monthly gross income (if available to me): Other current monthly income, including spousal maintenance/support, retirement, rental, interest, pensions, and lottery winnings: 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 Household Utilities/Telephone/Cable Medical/Dental/Drugs Health insurance Nursing care Tuition Child support Child care Spousal maintenance Car insurance Transportation Other expenses (explain) PAYMENT AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ LOAN BALANCE $ $ $ $ TOTAL MONTHLY EXPENSES $ STATEMENT OF ASSETS: List only those assets available to you and accessible without financial penalty. ESTIMATED VALUE Cash and bank accounts $ Credit union accounts $ Other liquid assets $ TOTAL ASSETS © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED APD $ PBW11f-090114 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No. THE BASIS FOR THE REQUEST IS: 5. [ ] DEFERRAL: A. [ ] My income 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 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. OR C. [ ] My income or the Estate/Ward/Protected Person's 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 $ $ $ TOTAL EXTRAORDINARY EXPENSES $ AMOUNT 6. [ ] WAIVER: I or the Estate/Ward/Protected Person, 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 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 steps you must take to avoid a judgment against you if you are still participating in a qualifying program. You may be ordered to repay any amounts that were waived if the court finds you were not eligible for the fee deferral or waiver. 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 or costs that are deferred but remain unpaid thirty (30) calendar days after entry of final judgment. OATH OR AFFIRMATION I declare under penalty of perjury that the foregoing is true and correct. Date Signature