(COURT'S JURISDICTIONAL NAME AND ADDRESS HERE) Case Number: Name of Petitioner/Plaintiff ORDER FOR ASSESSMENT AND COLLECTION OF INMATE COURT FEES AND COSTS Name of Respondent/Defendant THE COURT FINDS that Petitioner/Plaintiff is an inmate confined to a correctional facility operated by the Arizona State Department of Corrections who has initiated a civil action or proceeding, other than an action or proceeding for dissolution of marriage, legal separation, or annulment or establishment, enforcement or modification of child support. The amount of fees and costs due to date is $_________. (OR ALTERNATIVELY: [ ] A STATEMENT OF FEES AND COSTS DUE IS ATTACHED.) In accordance with A.R.S. § 12-302(E), IT IS ORDERED that a first-time payment of twenty percent (20%) is assessed as a partial payment of the amount due. If monies exist, the Arizona State Department of Corrections shall deduct this amount from the inmate's spendable account and remit it to the court. IT IS FURTHER ORDERED that the clerk of the court shall forward to the Arizona State Department of Corrections an updated accounting of the amount of actual court fees and costs. IT IS FURTHER ORDERED that the Arizona State Department of Corrections shall withhold twenty percent (20%) of all deposits in the inmate's spendable account until the actual court fees and costs are collected in full and shall annually forward any monies collected to this court. Upon the inmate's release, the Arizona State Department of Corrections shall forward the amount of fees and costs collected through the date of the release. IT IS FURTHER ORDERED that a copy of this order be mailed to the Arizona State Department of Corrections, Bureau of Business and Finance and to the inmate personally. DATED: [ ] Judicial Officer [ ] Special Commissioner Revised September 2014 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com