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Application For Deferral Or Waiver Of Service Of Process Fees For Orders Of Protection And Injunctions Against Harassment Form. This is a Arizona form and can be use in Fee Waiver And Deferral Statewide.
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Tags: Application For Deferral Or Waiver Of Service Of Process Fees For Orders Of Protection And Injunctions Against Harassment, Arizona Statewide, Fee Waiver And Deferral
(COURT’S JURISDICTIONAL NAME AND ADDRESS HERE)
Case Number:
Name of Petitioner/Plaintiff.
APPLICATION FOR DEFERRAL OR WAIVER OF
SERVICE OF PROCESS FEES FOR INJUNCTIONS
AGAINST HARASSMENT AND
CONSENT TO ENTRY OF JUDGMENT
Name of Respondent/Defendant.
STATE OF ARIZONA
)
COUNTY OF
)
ss.
IMPORTANT
This “Application for Deferral or Waiver of Court Fees and/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 step 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 “Consent
to Entry of Judgment” section of this application.
STATEMENTS MADE TO THE COURT UNDER OATH OR AFFIRMATION. I swear or affirm that the information
in this application is true and correct. I make this statement under the penalty of prosecution for perjury if it is
determined that I did not tell the truth.
I am requesting a deferral/waiver of the fee for service of process by a sheriff, marshal, constable or law
enforcement agency.
The basis for the request is:
1.
[ ] DEFERRAL:
A.
[ ] I receive governmental assistance from the state/federal program(s) marked below:
[ ] Temporary Assistance to Needy Families (TANF)
[ ] Food Stamps (Renamed Supplemental Nutrition Assistance Program or SNAP).
B.
[ ]
C.
[ ]
OR
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.
NOTE: 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. Gross monthly income includes your share of community
property income if available to you.
2.
If your income is greater than 150% of the poverty level, but you have proof of
extraordinary expenses (including medical expenses and costs of care for elderly or
disabled family members) or other expenses that the court finds are extraordinary that
reduce your gross monthly income to at or below 150% of the poverty level.
OR
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.
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2.
[ ] WAIVER:
A.
[ ]
B.
[ ]
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.
I receive government assistance from the federal program Supplemental Security Income (SSI).
NOTE: Every applicant, regardless of his or her financial circumstances, must complete the Financial
Questionnaire (below). If you submit the Application and Financial Questionnaire in person, you MUST
sign it in front of the court clerk; if you submit the form by mail or by a third party, you MUST sign it in front
of a notary public. You must submit proof that you receive governmental assistance. If you submit the
Application and Financial Questionnaire by mail or by a third party, please attach a copy of your proof of
governmental assistance.
FINANCIAL QUESTIONNAIRE
SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support and/or
spousal maintenance/support for):
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: My monthly income is:
Monthly gross income:
Employer name:
Employer address:
Employed since (month/year):
$
Other current monthly income, including spousal
maintenance/support, 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
$
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
$
Food/Household supplies
$
Utilities/Telephone
$
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Clothing
Medical/Dental/Drugs
Health Insurance
Nursing care
Laundry
Child Support
Child Care
Spousal Maintenance
Car Insurance
Gasoline/Bus Fare
Contributions to Employer
or Other Retirement Account
$
$
$
$
$
$
$
$
$
$
$
TOTAL MONTHLY INCOME
$
STATEMENT OF ASSETS: List only those assets available to you and accessible without financial penalty.
Equity is defined as market value minus any liens or loans.
ESTIMATED VALUE
Cash and Bank Accounts
$
Credit Union Accounts
$
Equity in:
1. Home
$
2. Other property
$
3. Cars/other vehicles
$
4. Other, including stocks, bonds, etc. $
5. Retirement accounts
$
TOTAL ASSETS
$
EXTRAORDINARY EXPENSES: For example, unusual medical needs, financial hardship, costs of care of elderly
or disabled family members. (Proof must be submitted.)
DESCRIPTION
AMOUNT
$
$
$
TOTAL EXTRAORDINARY EXPENSES
$
Note: If you receive a deferral and have unpaid fees at the end of your case you will receive a Notice of Court
Fees and Costs Due. This is to remind you that you may submit a supplemental application for further deferral or
waiver if you believe you need more time to pay or cannot afford to pay your court fees and costs. The court will
decide at that time whether or not you must pay. If you do not file a supplemental application, the original deferral
order remains in effect and a consent judgment may be entered against you if you do not pay within thirty calendar
days after entry of final judgment.
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 and/or costs that are deferred but remain unpaid after thirty (30) calendar days after entry of
final judgment. Judgment may be entered against me unless any one of the following applies:
A.
Fees and costs are taxed to another party;
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B.
C.
D.
E.
I have an established schedule of payments in effect and I am current with those payments;
I file a supplemental application for waiver or further deferral of fees and costs and a decision by the court
is pending;
In response to a supplemental application, the court orders that the fees and costs be waived or further
deferred; or
Within twenty days of the date the court denies the supplemental application, I either:
1.
Pay the fees and/or costs; or,
2.
Request a hearing on the court’s order denying waiver or further deferral. If I request a hearing,
the court cannot enter the consent judgment unless a hearing is held, further deferral or waiver is
denied and payment has not been made within the time prescribed by the court.
OATH OR AFFIRMATION
The contents of this document are true and correct to the best of my knowledge and belief.
Date
Signature
Printed Name
Date Signed or Affirmed
Judicial Officer, Deputy Clerk or Notary Public
My Commision Expires/Seal:
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