Fill and Sign the Fee Deferral Application to Delay Payment of Court Form

Page 1 of 4 ( COURT’S JURISDICTIONAL NAME AND ADDRESS HERE) Case Number: Name of Petitioner/Plaintiff. APPLICATION FOR DEFERRAL OR WAIVER OF APPELLATE COURT FEES AND COSTSAND CONSENT TO ENTRY OF JUDGMENT Name of Respondent/Defendant. IMPORTANT This Application for deferral of court fees and 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 costs that are deferred but remain unpaid after thirty (30) calendar days following the 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 steps you must take to avoid a judgment against you. Additional details about this process are discussed in the Consent to Entry of Judgment Section of this Application. STATE OF ARIZONA ) COUNTY OF ) ss 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 perju ry if it is determined that I did not tell the truth. I am requesting a deferral or waiver of the following fees and costs in my case: Filing fee - Direct Appeal or Special Ac tion to Ari zona Court of Appeals F iling fee - Pe tit ion for Re view to Ari zona Supre me Court F iling fee - Direct Appeal or Special Ac tion to Ari zona Supre me Court F iling fee - Cross-Pe tit ion for Re view or Response to Pe tit ion for Re view to Ari zona Supre me Court Page 2 of 4 The basis for the request is: 1. WAIVE R: I am p erm an ently un able to p ay. 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. OR 2. DEFE RR AL a. I rece iv e go ver nme ntal ass ista nce from t h e state /fe deral p ro g ram(s) c hecked b elo w : Te mporary Assis tance for Needy F am ilies (TAN F) Food S ta m ps Supple men tal Securi ty In co me (SS I) General Assis tance ( GA) If you checked either boxes 1 or 2a., please complete the Financial Questionnaire. You must then sign this application in front of the court clerk or a notary public if submitted by mail or a third party. Please be prepared to submit proof that you receive governmental assistance. If you are submitting this application by mail or a third party, please attach a photocopy of that proof. OR b . My i n co me is in su ff ic ie n t o r i s b are ly s u ff ic ie n t to meet t he daily esse ntia ls of l i f e, a n d 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. Although your income is greater than 150% of the poverty level, 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 that reduce your gross monthly income to at or below 150% of the poverty level. OR c. I d o no t h ave t he m oney to pay t h e c ourt fees a nd c o sts now. I can p ay t h e c ourt fees and costs at a later date. Explain. If you checked either boxes 2b. or 2c., please complete the Financial Questionnaire. You must then sign this application in front of the court clerk or a notary public if submitted by mail or a third party. FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List all persons you support (including paying child support and spousal maintenance): NAME RELATIONSHIP Page 3 of 4 STATEMENT OF INCOME AND EXPENSES ASSISTANCE: I receive assistance from: Ari zona Heal th Care Cost Con tain ment S ys tem (AHCCCS) Ari zona Long Term Care S ys tem (ALTCS) Ot her (e xplain): MONTHLY INCOME: My monthly income is: Monthly gross income: $ Employer name: Employer address: Employed since (month/year): Other current monthly income, including spousal maintenance, retirement, rental, interest, pensions, dividends, 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 employer or Other retirement account $ TOTAL MONTHLY PAYMENTS $ 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 $ Other, including stocks, bonds, etc. $ Retirement accounts $ TOTAL ASSETS: $ Page 4 of 4 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: At the end of your case, you will receive a Notice of Court Fees and Costs Due 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 costs. The court will decide at that time whether or not you must pay. 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 costs that are deferred, but that remain unpaid thirty (30) 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; B. I have an established schedule of payments in effect and I am current with those payments; C. I file a supplemental application for waiver or further deferral of fees and costs and a decision bythe court is pending; D. In response to a supplemental application, the court orders that the fees and costs be waived or further deferred; or E. Within twenty days of the date the court denies the supplemental application, I either: 1. Pay the fees and costs; or, 2. Request a hearing on the court’s order denying further deferral or waiver. If I request ahearing, the court c annot enter the consent j udgment unless a hearing is held, further deferral or waiver is denied and payment has not been made within the time prescribed by the court. ACKNOWLEDGMENT AND SIGNATURE UNDER OATH Today’s Date: Signature: Print Your Name: SUBSCRIBED AND SWORN or affirmed and acknowledged before me on (date) by . My Commission expires: Judicial Officer, Clerk or Notary Public 2001appeal1.wpd Revised 5/29/01