Revised 02.28.18 DEFERRAL OF FEES APPLICATION PINAL COUNTY INSTRUCTIONS AND FORMS Provided as a Public Service by AMANDA STANFORD Clerk of the Superior Court American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1 DeferralAppCOSCPinal02.28.18 Use only most current version DOCUMENTS REQUIRED FOR DEFERRAL When submitting the Deferral Application, supportin g documentation is required for approval. The court has listed below documentation that is acceptable. One of the following must be submitted with your Application: 1. A copy of your last two paycheck stubs. 2. A notarized statement of non - employment. Any persons you are living with at this time who is assisting you financially may sign a notarized document stating they are supporting you. 3. If you receive Food Stamps, SSI, unemployment or any governmental assistance we will need a copy of your letter of assignment/award or verification of the amount of assistance you receive. If your application is based upon your current income, the deferral will be granted if the established gross income is at or below these income levels indicated below and considering the number of related individuals in the household. If your income exceeds the amount listed below, you will be set up on a payment plan. Household Size (all rela ted individuals) Gross Monthly Income Level 150% Gross Monthly Income Level 175% Gross Monthly Income Level Level 200% Gross Monthly Income Level 225% 1 $1,507.50 $1,758.75 $2,010.00 $2,261.25 2 $2,030.00 $2,368.33 $2,706.67 $3,045.00 3 $2,552.50 $2,977.92 $3,403.33 $3,828.75 4 $3,075.00 $3,587.50 $4,100.00 $4,612.50 5 $3,597.50 $4,197.08 $4,796.67 $5,396.25 6 $4,120.00 $4,806.67 $5,493.33 $6,180.00 7 $4,642.50 $5,416.25 $6,190.00 $6,963.75 8* $5,165.00 $6,025.83 $6,886.67 $7,747.50 *For family units with more than 8 members, add $522.50 for each additional member at the 150% level, $609.58 at the 175%, $696.67 at the 200% level, and $783.75 at the 225% level. The Superior Court shall collect the minimum filing fee for each deferral appli cation submitted to the court. You may be eligible to defer this fee. Administrative Order 2015 - 97 American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF ARIZONA PINAL COUNTY (971 N. Jason Lopez Circle Bldg. A, Florence AZ 85132) Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Attorney E - mail Address: Representing Self (Without an Attorney) OR Attorney for Petitioner Respondent STATE OF ARIZONA ) COUNTY OF ) ss. Name of Petitioner/Plaintiff Case Number: S1100 APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES OR COSTS AND CONSENT TO ENTRY OF JUDGMENT Name of Respondent/Defendant 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, the cost of attendance at a n educational program required by A.R.S. 247 25 - 352, one certified copy of a of process 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 applican ts 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. [ ] DEFERRAL : I receive 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 2. [ ] WAIVER : [ ] I receive gove rnment assistance from the federal Supplemental Security Income (SSI) program. 3. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES. List all persons you support (including those you pay child support and/or spousal maintenance/support for): Revised June 2015 Page 1 of 3 AOC DFGF1F American LegalNet, Inc. www.FormsWorkFlow.com Case Number: NAME RELATIONSHIP STATEMENT OF INCOME AND EXPENSES Employer name: Employer phone number: [ ] I am unemployed (explain): gross income: $ MONTHLY INCOME My total monthly gross income: $ to me): $ Other current monthly income, including spousal maintenance/support, retirement, rental, interest, pensions, and lottery winnings: $ TOTAL MONTHLY INCOME $ MONTHLY EXP ENSES AND DEBTS: My monthly expenses and debts are: PAYMENT AMOUNT LOAN BALANCE 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) $ 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 $ Revised June 2015 Page 2 of 3 AOC DFGF1F American LegalNet, Inc. www.FormsWorkFlow.com Case Number: The basis for the request is: 4. [ ] DEFERRAL: A. [ ] 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. My gross income as computed on a monthly basi s 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 do not have the money to pay court filing fees and/or costs now. I can pay the filing fee s and/or costs at a later date. Explain. OR C. [ ] My 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 AMOUNT $ $ $ TOTAL EXTRAORDINARY EXPENSES $ 5. [ ] 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 are unlikely to change in the foreseeable future. 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 Date Judicial Officer, Deputy Clerk or Notary Public My Commission Expires/Seal: Revised June 2015 Page 3 of 3 AOC DFGF1F IMPORTANT This includes a By signing this Consent, you agre e 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 m uch 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 waive r. If your case is dismissed for any reason, the fees and costs are still due. American LegalNet, Inc. www.FormsWorkFlow.com