(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. Revised December 2010 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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 $ Revised December 2010 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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; Revised December 2010 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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: Revised December 2010 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com