CASE NUMBER: Plaintiff/Petitioner APPLICANT Complete all information in this section. Defendant/Respondent DATE: DEFERRED FEE APPLICATION INFORMATION NAME: ADDRESS: CITY: SSN: PHONE(H): ( ) YES NO STATE: ZIP CODE: PHONE (W): PHONE (Cell): ( ( ) ) DO YOU HAVE AN ATTORNEY? (FOR COURT USE ONLY: Do Not Write in this Section (except for your signature, below). FINANCIAL STATUS OF A DEFERRED FEE Special Commissioner Complete all information for each deferred fee in this section. FEE CODE # FEE CODE # FEE CODE # TYPE TYPE TYPE $ $ $ TOTAL AMOUNT OF FEES THAT HAVE BEEN DEFERRED: $ AMOUNT OF PARTIAL PAYMENT PAID AT TIME OF FILING: $ BALANCE: $ Special Commissioner Complete this section if a payment plan is set up. Cross out if deferred until further notice. Applicant: BALANCE OF DEFERRED FEE(S) DUE ON I (APPLICANT) SHALL MAKE ( WEEKLY DAY OF MONTHLY) PAYMENTS OF $ , 20 FINAL PAYMENT IS DUE ON OR BEFORE (BUT NO LATER THAN) THE DUE DATE ABOVE. ANY BALANCE LEFT OUTSTANDING AFTER THE DUE DATE WILL BE SENT TO A COLLECTIONS AGENCY. APPLICANT SIGNATURE: (FOR COURT USE ONLY: Do Not Write in this Section (except for your signature, below). ASSISTANCE RECEIVED/ INCOME INFORMATION TANF (TEMPORARY ASSISTANCE TO NEEDY FAMILIES) FOOD STAMPS COMMUNITY LEGAL SERVICES SSI < 150% Special Commissioner Check why deferred until further notice. Applicant: APPLICANT SIGNATURE: February 2, 2011 Page 1 of 1 GNF10f American LegalNet, Inc. www.FormsWorkFlow.com