Fill and Sign the Fee Waiver Law California Courts Cagov Form

Page 1 of 2 IMPORTANT This Application includes a Consent to Entry of Judgm ent. By signing this Consent, you agree a judgment may be entered against you for all fees that are deferred but remain unpaid thirty (30) calendar days after entry of final judgment. If payment has been postponed and not paid in full when due, you will receive a Notice of Court Fees and Costs Due indicating what steps you must take to avoid a judgment against you. Additional details about this process are described in the Consent to Entry of Judgment section of this Application. (COURT =S JURISDICTIONAL NAME AND ADDRESS HERE) Case Number: Name of Plaintiff/Petitioner. APPLICATION FOR DEFERRAL OR WAIVER OF SERVICE OF PROCESS FEES FOR INJUNCTIONS AGAINST HARASSMENT AND CONSENT TO ENTRY OF JUDGMENT Name of Defendant/Respondent. 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 fee for service of process by a sheriff, marshal, constable or law enforcement agency. The basis for the request is: G 1. WAIVER: 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 Page 2 of 2 G 2. DEFERRAL: a. I receive governmental assistance from th e state/federal program(s) checked below: G Temporary Assistance for Needy Families (TANF) G Food Stamps G Supplemental Security Income (SSI) G General Assistance (GA) 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 G b. My 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. OR G c. I do not have the money to pay the court fees and costs now. I can pay the court fees and costs at a later date. Explain. It would be useless or dangerous for me to try to obtain voluntary acceptance of service of process. CONSENT TO ENTRY OF JUDGMENT: By signing this Application, I agree a judgment may be entered against me for all fees and costs that are deferred but remain unpaid thirty (30) calendar 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 by the 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 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. 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 2003simappl.wpd Revised 11/19/03