Arizona Supreme Court Page 1 of 2 AOC DFGF10F-071017 Revised July 10, 2017 (COURT222S JURISDICTIONAL NAME AND ADDRESS HERE) Case Number: Name of Petitioner/Plaintiff ORDER ON SUPPLEMENTAL APPLICATION (WITHOUT HEARING) Name of Respondent/Defendant A SUPPLEMENTAL APPLICATION WAS FILED. THE COURT FINDS that the applicant (print name) : [ ] IS ELIGIBLE FOR A WAIVER [ ] The applicant is permanently unable to pay. [ ] The applicant receives Supplemental Security Income. [ ] The applicant previously was granted a deferral and his/her income and liquid assets have not changed and are unlikely to change in the foreseeable future. [ ] The court exercises its discretion to grant a waiver as necessary and appropriate. (A.R.S. 247 12-302 (L)) OR [ ] IS ELIGIBLE FOR FURTHER DEFERRAL of fees and costs. (Court must establish a schedule of payments) [ ] The applicant has shown good cause for further deferral. [ ] The court exercises its discretion to grant further deferral as necessary and appropriate. (A.R.S. 247 12-302 (L)) OR [ ] IS NOT ELIGIBLE FOR A WAIVER OR FURTHER DEFERRAL of fees and costs. IT IS ORDERED: (Check all boxes that apply) [ ] WAIVER IS GRANTED for unpaid fees and costs in the amount of $ . [ ] WAIVER IS DENIED. The applicant does not meet the financial criteria for waiver because: A waiver MUST BE granted upon proof that the applicant is permanently unable to pay or meets one of the eligibility factors listed above. [ ] FURTHER DEFERRAL IS GRANTED for unpaid fees and costs in the amount of $ . [ ] The applicant shall pay the entire amount due by (date). OR [ ] The applicant shall pay $ each (week, month etc.) until paid in full, beginning . [ ] FURTHER DEFERRAL IS DENIED because the applicant has not demonstrated good cause or it is not necessary or appropriate under A.R.S. 247 12-302 (L). American LegalNet, Inc. www.FormsWorkFlow.com Arizona Supreme Court Page 2 of 2 AOC DFGF10F-071017 Revised July 10, 2017 [ ] APPLICATION IS DENIED Your application is incomplete because: You are encouraged to submit a complete application before a consent judgment is entered against you. RIGHT TO HEARING. Unless a waiver is granted, you may request a hearing for a review of this order. The request must be made within twenty (20) days of the day this order was mailed or handed to you in court. No action for non-payment of fees and costs will be taken until the hearing is held. If you do NOT request a hearing, unless you are granted a payment plan, full payment is due within twenty (20) days from the day this order was mailed or handed to you in court. If full payment is not made within the time stated, a consent judgment may be entered against you for any amounts unpaid. DATED: [ ] Judicial Officer [ ] Special Commissioner American LegalNet, Inc. www.FormsWorkFlow.com