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Application For Deferral Of Court Fees And Or Costs And Consent To Entry Of Judgment Form. This is a Arizona form and can be use in Pima Local County.
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Tags: Application For Deferral Of Court Fees And Or Costs And Consent To Entry Of Judgment, Arizona Local County, Pima
Name: ___________________________________
Address: _________________________________
City, State, ZIP: ____________________________
Daytime Telephone No: ______________________
Representing Self, Without a Lawyer
ARIZONA SUPERIOR COURT, PIMA COUNTY
______________________________________
Case No. _________________
Petitioner
and
APPLICATION FOR DEFERRAL
OR WAIVER OF COURT FEES
AND/OR COSTS AND CONSENT
TO ENTRY OF JUDGMENT
______________________________________
Respondent
IMPORTANT: This Application for deferral of court fees and/or costs includes a Consent to Entry of Judgment. By signing
this Consent, you agree that a judgment may be entered against you for all fees and/or costs that are deferred, but that remain
unpaid after thirty (30) calendar days following the entry of final judgment. At the conclusion of the case you will receive a
Notice indicating how much is owed and what steps you must take to avoid a judgment against you if you are still unable to pay.
Additional details about this process are discussed in the Judgment Section of this Application.
STATE OF ARIZONA
COUNTY OF PIMA
)
)ss
)
STATEMENTS MADE TO THE COURT UNDER OATH.
I swear or affirm that the information in this
application is true and correct. I make this statement under penalty of prosecution for perjury if it is
determined that I did not tell the truth.
I am requesting a deferral or waiver of the following fees and/or costs in my case:
Any or all of the following: All filing fees, fees for issuance of summonses and subpoenas, fees for obtaining
one certified copy of a temporary order in a domestic relations case, a final order, judgment or decree in all
civil proceedings, child support payment history and fees for attending the Domestic Relations Education on
Children’s Issues Program, pursuant to A.R.S. § 25-355.
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 preparation of the record on appeal.
Court reporter’s fees of reporters or transcribers employed by the court for the preparation of the transcript.
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deferral-application for deferral/waiver consent to judgment.form
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The basis for this request is:
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.
DEFERRAL: The basis for the deferral request is that I receive governmental assistance from the
state/federal program(s) checked below:
Temporary Assistance to Needy Families (TANF)
Food Stamps (Qwest Card)
Supplemental Security Income (SSI) for disabilities
General Assistance (GA)
IF YOU CHECKED ONE OF THE BOXES ABOVE (Wavier or Deferral), you must complete the Financial
Questionnaire. You must sign this application in front of the court clerk or a notary public, if submitted by
mail or a third party. You must also submit proof that you receive governmental assistance. If you are
submitting this application by mail or a third party, you must attach a photocopy of that proof.
OR
The basis for the deferral or waiver request is:
My income is insufficient or 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. You must fill out the
Financial Questionnaire below.
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. (To see if you qualify, a table showing 150% of the poverty levels by family size is
attached.) Gross monthly income includes your share of community property income if available to you.
2. If your income exceeds 150% of the poverty level, but you have proof of extraordinary expenses,
including medical expenses, costs of care for elderly or disabled family members or other expenses that
the court finds are extraordinary and that reduce your gross monthly income to 150% of the poverty level
or below.
OR
IF NONE OF THE ABOVE REASONS APPLY, you still may request a deferral or waiver of court fees
and/or costs for good cause shown. If granted, the court either will postpone payment until the
conclusion of the case or establish a schedule for you to make payments.
The basis for the deferral or waiver request is:
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.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
You must fill out the Financial Questionnaire (see next page).
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deferral-application for deferral/waiver consent to judgment.form
Revised 02.11.11
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FINANCIAL QUESTIONNAIRE
SUPPORT RESPONSIBILITIES: List the individuals who you support (including paying child support and/or
spousal maintenance):
NAME
RELATIONSHIP
_________________________________________
_______________________________________
_________________________________________
_______________________________________
_________________________________________
_______________________________________
STATEMENT OF INCOME AND EXPENSES
ASSISTANCE: I receive assistance from:
Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
Other (explain): _______________________________________
_____________________________________________________
MONTHLY INCOME:
Employer’s name:
__________________________________________________
Employer’s address: __________________________________________________
Employed since (month/year): ____________________
Monthly gross income:
$____________
Other current monthly income, including spousal
maintenance, 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:
$___________
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deferral-application for deferral/waiver consent to judgment.form
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MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are:
PAYMENT AMOUNT
LOAN BALANCE
Rent/Mortgage Payment
$
$______________
Car Payment
$
$______________
Credit Card Payments
$
$______________
$
$______________
Explain:
Other Payments & Debts:
Explain:
Food/Household Supplies
$
Utilities/Telephone
$
Clothing
$
Medical/Dental/Drugs
$
Health Insurance
$
Nursing Care
$
Laundry
$
Child Support
$
Child Care
$
Spousal Maintenance actually paid
$
Car Insurance
$
Gasoline/Bus Fare
$
Contributions to Employer or
Other Retirement Account
$
TOTAL MONTHLY PAYMENTS
$_____________
STATEMENT OF ASSETS: Equity is defined as market value minus any liens or loans. List only those assets
available to you and are accessible without financial penalty.
ESTIMATED VALUE
Cash & Bank Accounts
$____________________
Credit Union Accounts
$____________________
Equity in:
1. Home
$____________________
2. Other Property
$____________________
3. Cars/Other Vehicles
$____________________
Retirement Accounts
$____________________
Other, including stocks, bonds, etc.
$____________________
TOTAL ASSETS:
$______________
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deferral-application for deferral/waiver consent to judgment.form
Revised 02.11.11
American LegalNet, Inc.
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EXTRAORDINARY EXPENSES: Other facts that support this application are: (For example, describe and
provide proof of unusual medical needs, financial hardship, costs of care of elderly or disabled family members)
DESCRIPTION
AMOUNT
$________________
$________________
TOTAL EXTRAORDINARY EXPENSES
5.
$______________
CONSENT TO JUDGMENT: By signing this application, you agree that a judgment may be entered
against you for all fees and/or costs not taxed to another party that are deferred, but that remain unpaid after
thirty (30) calendar days following entry of final judgment. Judgment automatically will be entered against
you unless any one of the following applies:
A. Fees and costs are taxed to another party;
B. You make a supplemental application for waiver or further deferral of fees and/or costs and a decision by
the court is pending;
C. The court orders that the fees and costs be waived or further deferred; or
D. Within twenty (20) days of the date the court denies the supplemental application, you either:
1. Pay the fees and/or costs; or
2. Request a hearing on the court’s order denying waiver or further deferral. If you request a hearing,
the court cannot enter the consent judgment unless a hearing is held, waiver or further deferral is
denied and payment has not been made within the time prescribed by the court.
At the end of your case, you will receive a notice reminding you that you may submit a supplemental application
for further deferral or waiver if you believe you still cannot afford to pay your court fees and/or costs. The court
will decide at that time whether or not you must pay.
ACKNOWLEDGMENT AND SIGNATURE UNDER OATH
Today’s Date:
Signature: ____________________________________
Print Your name:_______________________________
SUBSCRIBED AND SWORN or affirmed and acknowledged before me on (date) ___________________
By___________________________________________
My Commission Expires:
_____________________________________________
Judicial Officer, Clerk or Notary Public
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deferral-application for deferral/waiver consent to judgment.form
Revised 02.11.11
American LegalNet, Inc.
www.FormsWorkFlow.com