Fee Deferral Application

Application for Deferral or Waiver of Appellate Court Fees and Costs and Consent to Entry of Judgment

(COURT’S JURISDICTIONAL NAME AND ADDRESS HERE)

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 perjury 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:

The basis for the request is:

1. WAIVER: I am permanently unable to pay. 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. DEFERRAL

FINANCIAL QUESTIONNAIRE

SUPPORT RESPONSIBILITIES:

List all persons you support (including paying child support and spousal maintenance):

STATEMENT OF INCOME AND EXPENSES

ASSISTANCE: 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:

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:

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.

EXTRAORDINARY EXPENSES:

For example, unusual medical needs, financial hardship, costs of care of elderly or disabled family members. (Proof must be submitted.)

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:

1. Fees and costs are taxed to another party;
2. I have an established schedule of payments in effect and I am current with those payments;
3. I file a supplemental application for waiver or further deferral of fees and costs and a decision by the court is pending;
4. In response to a supplemental application, the court orders that the fees and costs be waived or further deferred; or
5. 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 a hearing, the court cannot enter the consent judgment unless a hearing is held, further deferral or waiver is denied and payment has not been made within the time prescribed by the court.