Fill and Sign the Application for Deferral of Court Fees Andor Costs Superior Court Form

Name: ____________________________________Address: ___________________________________City, State, Zip: _____________________________Telephone No.: ______________________________Representing ______________________________ THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of Maricopa _______________________________________________In the Matter of: CASE NO.[ ] Guardianship/Conservatorship [ ] Probate of Estate APPLICATION FOR DEFERRAL OF COURT FEES AND COSTS And CONSENT TO ENTRY OF JUDGMENT [ ] An adult [ ] A minor [ ] A deceased person_______________________________________________________________________________WAIV 4 STATE OF ARIZONA ) )ss COUNTY OF _________________ )STATEMENTS MADE TO THE COURT UNDER OATH. I swear that the information given in this Application is true and correct to the best of my knowledge. I make this statement on behalf of the estate under the penalty of prosecution for perjury if it is determined that I did not tell the truth.1. I am requesting a deferral of the following fees and/or costs in my case: Any or all of the following: All filing fees, fees for the issuance of summonses and subpoenas, fees for obtaining one certified copy of a temporary order in a domestic relations case, a final order, judgment or decree in all civil proceedings, child support payment history and fees for attending the Domestic Relations Education on Children’s Issues Program, pursuant to A.R.S. § 25-355. Fees for service of process by a sheriff, marshal, constable or local law enforcement agency (fill out separate affidavit form). Fees for service by publication (fill out separate affidavit form). Filing fees and photocopy fees for the preparation of the record on appeal. Court reporter’s fees of reporters or transcribers employed by the court for the preparation of the transcript. Court accountant fees and costs Court investigator fees and costs 2. My interest in this case is (check on box): Petitioner for Appointment of a Guardian/Conservator for an Adult or a Minor Petitioner for Appointment of a Personal Representative for the Estate Creditor filing a Demand for Notice Other (describe): __________________________________________________________________________________ IMPORTANT This Application for deferral of court fees and/or costs includes a Consent to Entry of Judgment. By signing this Consent, you agree that a judgment may be entered against you for all fees and/or costs that are deferred, but that remain unpaid after thirty (30) calendar days following the entry of final judgment. At the conclusion of the case you will receive a Notice indicating how much is owed and what steps you must take to avoid a judgment against you if you are still unable to pay. Additional details about this process are discussed in Consent to Judgment Section of this Application. 3.The basis for the deferral request is that I or the Estate/Ward/Protected Person receive governmental assistance from the state/federal program(s) checked below: Temporary Assistance to Needy Families (TANF) Food Stamps Supplemental Security Income (SSI) General Assistance (GA)IF YOU CHECKED ONE OF THE BOXES ABOVE, go directly to the end of the last page and date and sign the Application in front of the clerk or a notary public. You do not need to complete other parts of this form. OR 4.The basis for the deferral request is:A. My or the Estate/Ward/Protected Person’s 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. You must fill out the Financial Questionnaire below. 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. (To see if you qualify, a table showing 150% of the poverty levels by family size is attached.) Gross monthly income includes your share of community property income if available to you. 2.If your income exceeds 150% of the poverty level, but you have proof of extraordinary expenses, including medical expenses, costs of care for elderly or disabled family members or other expenses that the court finds are extraordinary and that reduce your gross monthly income to at or below 150% of the poverty level. OR IF NONE OF THE ABOVE REASONS APPLY, you still may request a deferral of court fees and/or costs for good cause shown. If granted, the court either will postpone payment until the conclusion of the case or establish a schedule for you to make payments.B. I or the Estate/Ward/Protected Person 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. ____________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ You must fill out the Financial Questionnaire below. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List the individuals who you support (including paying child support and/or spousal maintenance):NAME RELATIONSHIP _______________________________________ _________________________________________________ _______________________________________ _________________________________________________ _______________________________________ _________________________________________________ STATEMENT OF INCOME AND EXPENSESASSISTANCE: 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:Employer name: __________________________________________________________________________________________Employer address: ________________________________________________________________________________________Employed since (month/year): _______________________________________________________________________________Monthly gross income: $ ____________________Other current monthly income, including spousal maintenance, 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 $ ___________________$ ____________________Explain: _________________________________________________________________Food/Household supplies $ ___________________Utilities/Telephone$ ___________________Clothing$ ___________________Medical/Dental/Drugs $ ___________________Health Insurance$ ___________________Nursing care$ ___________________Laundry$ ___________________Child Support $ ___________________Child Care $ ___________________Spousal Maintenance $ ___________________Car Insurance $ ___________________Gasoline/Bus Fare $ ___________________Contributions to Employeror Other Retirement Account$ ___________________TOTAL MONTHLY PAYMENTS$ STATEMENT OF ASSETS: Equity is defined as market value minus any liens or loans. List only those assets available to you and accessible without financial penalty. ESTIMATED VALUE Cash and Bank Accounts $ ___________________Credit Union Accounts$ ___________________Equity in: 1. Home$ ___________________2. Other property $ ___________________3. Cars/other vehicles $ ___________________Other, including stocks, bonds, etc. $ ___________________Retirement Accounts $ ___________________TOTAL ASSETS:$ EXTRAORDINARY EXPENSES: Other facts that support this application are: (For example, describe and provide proof of unusual medical needs, financial hardship, costs of care of elderly or disabled family members)DESCRIPTION AMOUNT___________________________________________________ $ ______________________________________________________________________$ ______________________________________________________________________$ ___________________TOTAL EXTRAORDINARY EXPENSES$ CONSENT TO JUDGMENT: By signing this Application, you agree that a judgment may be entered against you for all fees and/or costs not taxed to another party that are deferred, but that remain unpaid after thirty (30) calendar days following the entry of final judgment. Judgment automatically will be entered against you unless any one of the following applies:A. Fees and costs are taxed to another party;B. You make a supplemental application for waiver or further deferral of fees and/or costs and a decision by the court is pending;C. The court orders that the fees and costs be waived or further deferred; orD. Within twenty days of the date the court denies the supplemental application, you either:1. Pay the fees and/or costs; or, 2. Request a hearing on the court’s order denying waiver or further deferral. If you request a hearing, the court can not enter the consent judgment unless a hearing is held, waiver or further deferral is denied and payment has not been made within the time prescribed by the court.At the end of your case, you will receive a notice reminding you that you may submit a supplemental application for further deferral or waiver if you believe you still cannot afford to pay your court fees and/or costs. The court will decide at that time whether or not you must pay. ACKNOWLEDGMENT AND SIGNATURE UNDER OATH Date: ___________________________________ ___________________________________________ ______ Signature: Print Your Name: _________________________________________________ SUBSCRIBED AND SWORN before me this _____ day of ______________________________, 199 _____ by ______________________________________________Notary Public _____________________ ________________________________ (Seal)Name: ____________________________________Address: ___________________________________City, State, Zip: _____________________________ Telephone No.: ______________________________Representing _______________________________ THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of Maricopa _______________________________________________In the Matter of: CASE NO.[ ] Guardianship/Conservatorship [ ] Probate of Estate ORDER FOR [ ] Deferral of Court Fees and/or Costs (ODC) [ ] Order Waiving Court Fees and/or Costs (OWC) [ ] Order Denying Deferral/Waiver Of Court Fees and Costs (ODD)ANDCONSENT TO ENTRY OF JUDGMENT [ ] An adult [ ] A minor [ ] A deceased person_______________________________________________________________________________WAIV 4 THE COURT FINDS that the applicant (print name):1. IS NOT ELIGIBLE FOR A DEFERRAL of fees and/or costs. OR 2. IS ELIGIBLE FOR A DEFERRAL based on financial eligibility for a deferral of fees and costs. As required by state law, the applicant has signed a consent to entry of judgment. OR 3. IS ELIGIBLE FOR DEFERRAL of fees and/or costs on good cause shown. OR 4. IS ELIGIBLE FOR WAIVER of fees and/or costs at the courts discretion (A.R.S. §12-302(M)).IT IS ORDERED:1. DEFERRAL DENIED for the following reason(s): The application is incomplete because: ___________________________________________ __________________________________________________________________________ __________________________________________________________________________ You are encouraged to submit a complete application before a consent judgment is entered against you. The applicant does not meet the financial criteria for fee deferral because: ________________ ________________________________________________________________________ __________________________________________________________________________ A deferral MUST BE granted if the applicant is receiving public assistance benefits or has an income that is insufficient or barely sufficient to meet the daily essentials of life and that includes no allotment that could be budgeted to pay the fees and/or costs necessary to gain access to the court or if the applicant demonstrates other good cause. This is a class action. The applicant is an incarcerated felon and this is not a domestic relations action. 2. DEFERRAL GRANTED for the following fees and/or costs in this court: Any or all filing fees, fees for the issuance of summonses and subpoenas, fees for obtaining one certified copy of a temporary order in a domestic relations case, or a final order, judgment or decree in all civil proceedings, child support payment history report or fees for attending Domestic Relations Education on Children’s Issues Program pursuant to A.R.S. §25-355. Fees for service of process by a sheriff, marshal, constable or local law enforcement agency Fees for service by publication Filing fees and photocopy fees for the preparation of the record on appeal Court reporter’s fees of reporters or transcribers employed by the court for the preparation of the transcript. Court accountant fees and costs. Court investigator fees and costs. IF A DEFERRAL IS GRANTED, PLEASE CHECK ONE OF THE FOLLOWING BOXES. NO PAYMENTS WILL BE DUE UNTIL FURTHER NOTICE (Only applies to Finding #2 or #3). SCHEDULE OF PAYMENTS (Only applies to Finding #3).The applicant shall pay $ ________________ each ___________________ (week, month, etc.) until paid in full, beginning ______________________________________________________________. 3. WAIVER GRANTED for all fees and/or costs of this case that may be waived under A.R.S. §12- 302(I).4.RIGHT TO JUDICIAL REVIEW. If the application is denied or a payment schedule set by a special commissioner, you may request the decision be reviewed by a judge or judicial officer. The request must be made within twenty (20) days of the day the order was mailed or delivered to you. If a schedule of payments has been established, payments shall be suspended until a decision is made after the judicial review. The judicial review shall be held as soon as possible. 5. CONSENT TO ENTRY OF JUDGMENT. In accordance with state law and procedures adopted by the Arizona Supreme Court, a consent judgment shall be entered against the applicant for all fees and costs that are deferred and not taxed to another party, but that remain unpaid after thirty (30) calendar days following the entry of final judgment unless any one of the following applies: A.Fees and costs are taxed to another party; B.A supplemental application for waiver or further deferral remains pending; C.The court orders that the fees and costs be waived or further deferred; orD. Within twenty days of the date the court denies the supplemental application, the applicant: 1.Pays the fees; or, 2.Requests a hearing on the court’s order denying waiver or further deferral. If the applicant requests a hearing, the court shall not enter the consent judgment unless a hearing is held, waiver or further deferral is denied and payment has not been made within the time prescribed by the court. 6.DUTY TO REPORT CHANGE IN FINANCIAL CIRCUMSTANCES. An applicant who is granted a deferral shall promptly notify the court of the change in financial circumstances during the pendency of the case that would affect the applicant’s ability to pay court fees and costs. Any time the applicant appears before the court on this case, the court may inquire as to the applicant’s financial circumstances.DATED: _____________________________ ____________________________________ ______ [ ] Judicial Officer or [ ] Special Commissioner Name: ____________________________________Address: ___________________________________City, State, Zip: _____________________________Telephone No.: ______________________________Representing ______________________________ THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of Maricopa _______________________________________________In the Matter of: CASE NO.[ ] Guardianship/Conservatorship [ ] Probate of Estate AFFIDAVIT IN SUPPORT OF APPLICATION FOR DEFERRAL OR WAIVER OF SERVICE OF PROCESS COSTS [ ] An adult [ ] A minor [ ] A deceased person_______________________________________________________________________________WAIV 4 STATE OF ARIZONA ) )ss COUNTY OF _________________ )STATEMENTS MADE TO THE COURT UNDER OATH. 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 have requested a deferral of the following fees in my case:1. Fees for service of process by a sheriff, marshal, constable or local law enforcement agency: In support of my request, I state that (check and complete any that apply): I have attempted to obtain voluntary acceptance of service of process without success on the person to be served. It would be useless or dangerous for me to try to obtain voluntary acceptance of service by the person to be served because (explain): ________________________________________ ________________________________________________________________________ __ There is an enforceable Order of Protection or Injunction Against Harassment between the parties. 2. Fees for publication: In support of my request, I state that I have attempted to locate the person to be served but I have been unable to locate that person (check and complete any that apply): This is what I did to try to find the other party (explain): _____________________________ ________________________________________________________________________ __ I have contacted the person(s) listed below to try to find the location of the other party. NAME ADDRESS _________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ACKNOWLEDGMENT AND SIGNATURE UNDER OATH Date: ____________________________ ____________________________________ ______ Signature SUBSCRIBED AND SWORN before me this _____ day of ________________________________, 199 _____ by ____________________________________________Notary Public ______________________ _________________________(Seal) INFORMATION FOR SERVICE BY LAW ENFORCEMENT You must answer this if you want a sheriff, marshal, constable or local law enforcement agency to serve papers on the other party:To the best of my knowledge, as of _____________________, the last known address of the person to be served was: ______________________________________________________________________________________. Name:_________________________________________________Address:_______________________________________________City, State. Zip:_________________________________________Telephone:_____________________________________________State Bar Code:_________________________________________Client:_________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of ___________________ ___________________________________________IN RE THE MATTER OF [ ] Guardian [ ] Conservator [ ] Estate CASE NO. REQUEST FOR HEARINGAND ORDER FOR HEARING [ ] Adult [ ] Minor [ ] Decedent__________________________________________________________________________________ WAIV 4NOTICE: To ensure that the Consent Judgment is not entered, you must mail or hand-deliver a copy of this document to the Clerk of the Court, Collections Department, 201 West Jefferson, 1st Floor, Phoenix, Arizona 85003.Check at least one of the following:I REQUEST A HEARING BECAUSE:1. I am dissatisfied with the decision on the application for deferral or supplemental application for waiver or further deferral.2. I do not agree with the amount of unpaid fees and costs on the itemized statement provided by the court. I request a hearing on the amount due the court.Date : ______________________________________ ______________________________________ _________ Signature Print your name : ____________________________________________ =============================================================================== ==== THE COURT COMPLETES THIS SECTION IT IS ORDERED that a hearing is set. Hearing Date: Hearing Time: Hearing Location: Dated: Judicial Officer/Special Commissioner Mailed/hand-delivered to applicant on , by =============================================================================== ====Name:_________________________________________________Address:_______________________________________________City, State. Zip:_________________________________________Telephone:_____________________________________________State Bar Code:_________________________________________Client:_________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of ___________________ ___________________________________________IN RE THE MATTER OF [ ] Guardian [ ] Conservator [ ] Estate CASE NO. SUPPLEMENTAL INFORMATION FORAPPLICATION FOR WAIVER OF FEES AND COSTS FOR [ ] Service of Process [ ] Publication [ ] Adult [ ] Minor [ ] Decedent__________________________________________________________________________________ WAIV 4 STATE OF ARIZONA ) )ss County of ______________ )1.The information stated below is true and correct. 2.I am the Petitioner in this case, and I have received a Waiver of Filing Fees in this case. 3. I am filing this Supplemental Information so I can proceed with serving Notice in this court case, as required by Arizona law. REQUEST FOR WAIVER OF SERVICE OF PROCESS COSTS 1.FOR GUARDIANS OR CONSERVATORS: A waiver of Service of Process costs is necessary because :[ ] I have attempted to obtain voluntary acceptance of service of process without success on the person to be served with notice. [ ] It would be useless or dangerous for me to try to obtain voluntary acceptance of service by the person to be served because: ______________________________________________________ ____________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________. REQUEST FOR WAIVER OF PUBLICATION FEES 2.A waiver of costs to publish notice is necessary because the residence and whereabouts of the party or parties entitled to notice are unknown to me and: [ ]The party or parties I must give notice to by publication are:NAMELAST KNOWN ADDRESS DATE OF LAST RELATIONSHIP KNOWN ADDRESS 1. ___________________________________ ___________________ __________________ 2. ___________________________________ ___________________ __________________ 3. ___________________________________ ___________________ __________________ 4. ___________________________________ ___________________ __________________ [ ]I have made a diligent search to find out the residence and whereabouts of the Person(s), but the search has failed to reveal any information concerning the person(s) residence or whereabouts.[ ] I have contacted the following persons to find out the location of the persons listed above: NAMEADDRESS FOR #1 above _____________________________ ____________________________________ ______ _____________________________ ____________________________________ ______ FOR #2 above _____________________________ ____________________________________ ______ _____________________________ ____________________________________ ______ FOR #3 above _____________________________ ____________________________________ ______ _____________________________ ____________________________________ ______ FOR #4 above _____________________________ ____________________________________ ______ _____________________________ ____________________________________ ______ [ ]If this is a case about a Petition for Appointment of Conservator or Application for Probate of a Will, I understand that the law requires a Notice to Creditors to be published once a week for three consecutive weeks.[ ] If this is a case for a Application for Formal Probate a Will, I understand that the law requires that the Notice of Appointment or Informal Probate must be published one time. I WILL PROMPTLY NOTIFY THE COURT IN WRITING IF ANY FINANCIAL CIRCUMSTANCES CHANGE DURING THE TERM OF THIS COURT ACTION. IF THAT HAPPENS, I OR THE ESTATE MAY BE ABLE TO PAY THE FEES THAT HAVE BEEN WAIVED OR DEFERRED. __________________________________________Signature of Applicant SUBSCRIBED AND SWORN before me this _______ day of _____________________________199______, by______________________________________________. Notary Public ______________________ _____________________________(Seal)Name:_________________________________________________Address:_______________________________________________City, State. Zip:_________________________________________Telephone:_____________________________________________State Bar Code:_________________________________________Client:_________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of ___________________ ___________________________________________ IN RE THE MATTER OF [ ] Guardian [ ] Conservator [ ] Estate CASE NO. ORDER FOR WAIVER OF [ ] Service of Process [ ] PublicationFEES AND COSTS [ ] Adult [ ] Minor [ ] Decedent______________________________________________________________________________WAIV 4THE COURT FINDS THAT [ ]For Service of Process in a guardianship or conservatorship case, the Applicant has previously demonstrated a need for waiver of court fees and costs pursuant to A.R.S. 12-306. The Applicant has further demonstrated the need for a waiver of service of process fees and costs as follows:[ ] The Applicant has attempted to obtain voluntary acceptance of service of process without success on the person to be personally served with notice; OR[ ] It would be useless or dangerous for the Applicant to try to obtain voluntary acceptance of service by the person to be served. [ ] For Publication, the Applicant has previously demonstrated a need for a waiver of court fees and costs under A.R.S. 12-306. The applicant has further demonstrated a need for a waiver of service by publication fees and costs as follows: [ ]The applicant has made a diligent search to find out the residence and whereabouts of the following person(s) but the search has failed to reveal any information concerning the person’s(s’) residence or whereabouts.NAME LAST KNOWN ADDRESS DATE OF LAST RELATIONSHIP KNOWN ADDRESS 1. ___________________________________ ___________________ __________________ 2. ___________________________________ ___________________ __________________ 3. ___________________________________ __________________ __________________ 4. ___________________________________ ___________________ __________________ [ ]The applicant is required to publish a notice of hearing or Notice to Creditors once a week for three weeks.[ ] The applicant is required by law to publish a Notice of Informal Appointment or Informal Probate one time as required by law. IT IS ORDERED THAT the following fees and costs are waived:[ ]Service of Process by the Maricopa County Sheriff's Office.[ ] Publication in the Arizona Business Gazette.IT IS FURTHER ORDERED THAT The applicant shall promptly notify this court in writing of any change in the Applicant's financial circumstances during the time the case is pending which may affect the applicant's or the estate’s ability to pay the waived fees and costs. The applicant must keep a copy of this order to present to the Court upon request.DONE this _____ day of ___________________________, 199_______. _____________________________________________Probate Registrar/Special Commissioner