OPTIONAL USE CONFIDENTIAL PERSONAL FINANCIAL AFFIDAVIT STATE OF ARIZONA COUNTY OF ) ) ss. I, ________________________________________, am an applicant for a DEFERRAL OR WAIVER OF COURT FEES AND COSTS PURSUANT TO A.R.S. § 12-302. The Application for Deferral or Waiver of Court Fees and Costs requires a Consent to Entry of Judgment. By signing the Consent, I have agreed that a judgment may be entered against me for all fees and costs that are deferred but remain unpaid thirty (30) calendar days after entry of final judgment. I understand that collection efforts include referring the judgment to a collection program (A.R.S. § 12-116.03), entry into a tax intercept program (A.R.S. § 42-1122(b)), and reporting of the debt to credit bureaus (A.R.S. § 12-288), which require the use of my social security number. I understand that the information provided is collected for administrative purposes and shall be maintained as confidential information under Rule 123, Rules of the Supreme Court, unless needed to enforce the consent judgment as specified above. Therefore, I declare under penalty of perjury that the foregoing is true and correct. I hereby verify that my social security number is _____ - ___ - _____. OR I hereby verify that I do not possess a valid social security number. Signature Applicant's Printed Name SUBSCRIBED AND SWORN before me this _____ day of _____________, 20_______. By . My Commission Expires/Seal: Judicial Officer, Deputy Clerk or Notary Public Revised September 2014 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com