Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Representing Self (Without an Attorney) OR Attorney for Petitioner OR Respondent FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the matter of Case Number PB REQUEST AND ORDER FOR HEARING Name of protected (or deceased) person NOTICE: To ensure that the Consent Judgment is not entered, you must mail or hand-deliver a copy of this document to the Clerk of the Court, Collections Department, 201 West Jefferson, 1st Floor, Phoenix, Arizona 85003. Check at least one of the following: I request a hearing on the denial of my supplemental application for waiver or further deferral. I do not agree with the amount of unpaid fees and costs on the itemized statement provided by the court. I request a hearing on the calculation of the unpaid fees and/or costs. Date: Print your name: Signature: . THE COURT COMPLETES THE FOLLOWING SECTION IT IS ORDERED scheduling a hearing on the above matter. Hearing Date: Hearing Time: Hearing Location: Hearing Officer: Dated: Judicial Officer OR Mailed/hand-delivered to applicant on , by Special Commissioner � Superior Court of Arizona in Maricopa County October 14, 2010 ALL RIGHTS RESERVED Page 1 of 1 PBW31f Use current form ROH American LegalNet, Inc. www.FormsWorkFlow.com