(COURT'S JURISDICTIONAL NAME AND ADDRESS HERE) 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. Case Number: Name of Petitioner/Plaintiff 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 an educational program required by A.R.S. � 25-352, 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, 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. [ ] 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 government 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 American LegalNet, Inc. www.FormsWorkFlow.com AOC DFGF1F Case Number: __________________ 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 $ Revised June 2015 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com AOC DFGF1F 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 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 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 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. 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 Applicant's Printed Name Date My Commission Expires/Seal: Judicial Officer, Deputy Clerk or Notary Public Revised June 2015 Page 3 of 3 AOC DFGF1F American LegalNet, Inc. www.FormsWorkFlow.com