Fill and Sign the This Application for Deferral of Court Fees Andor Costs Includes a Consent Form

Name: _________________________________________________Address: _______________________________________________City, State, Zip: _________________________________________Telephone Number: ______________________________________State Bar Number: _______________________________________Client: _________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of _________________________ ___________________________________________ CASE NO. ___________________________________, Petitioner, APPLICATION FOR DEFERRAL vs OF COURT FEES AND/OR COSTS ___________________________________, AND Respondent CONSENT TO ENTRY OF JUDGMENT ______________________________________________________________________________WAIV5STATE OF ARIZONA )COUNTY OF ) ssSTATEMENTS MADE TO THE COURT UNDER OATH. I swear that the information in this application is true and correct to the best of my knowledge and belief. I make this statement under the penalty of perjury. 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. 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 Statement 5 of this Application. 2.The basis for the deferral request is that I 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 ANY ONE OF THE BOXES ABOVE, go directly to the last page and date and sign the Application in front of the Court Clerk or a Notary Public. (You do not need to complete the rest of this form). OR 3.The basis for the deferral request is:A. 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. 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 monthly income 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 defer payment until the conclusion of the case or establish a payment schedule for you. B. I 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 1.SUPPORT RESPONSIBILITIES: List the individuals who you support (including paying child support and/or spousal maintenance): NAME RELATIONSHIP 2.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: Date employment began: 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 $ 4.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: $ 5.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 $ 6.5.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 of Petitioner Printed NameSUBSCRIBED AND SWORN or affirmed and acknowledged before me on (date) by .Notary Public or Clerk of the Court (Seal) Name: _________________________________________________Address: _______________________________________________City, State, Zip: _________________________________________Telephone Number: ______________________________________State Bar Number: _______________________________________Client: _________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of _________________________ ___________________________________________ CASE NO. ___________________________________, Petitioner, ORDER DEFERRING COURT FEES AND/OR COSTS (ODC) vs. WAIVING COURT FEES AND/OR COSTS (OWC) DENYING DEFERRAL/WAIVER OF COURT FEES AND COSTS (ODD) ___________________________________, AND Respondent CONSENT TO ENTRY OF JUDGMENT ___________________________________________________________________________________WAIV5THE COURT FINDS that the applicant (print name): :1. IS NOT ELIGIBLE FOR A DEFERRAL of fees and/or costs. 2. IS ELIGIBLE FOR A DEFERRAL financial eligibility for a deferral of fees and costs. As required by state law, the applicant has signed a consent to entry of judgment.3. IS ELIGIBLE FOR DEFERRAL of fees and/or costs on good cause shown.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. 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/Special Commissioner Name: _________________________________________________Address: _______________________________________________City, State, Zip: _________________________________________Telephone Number: ______________________________________State Bar Number: _______________________________________Client: _________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of _________________________ ___________________________________________ CASE NO. ___________________________________, Petitioner, AFFIDAVIT IN SUPPORT OF APPLICATION FOR DEFERRAL OR WAIVER OF SERVICE vs. OF PROCESS OR PUBLICATION COSTS ___________________________________, Respondent ___________________________________________________________________________________WAIV5STATE 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 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 of SUBSCRIBED AND SWORN before me this _____ day of , 199_____by . Notary Public or Court Clerk: (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 (date) , the last known address of the person to be served was: . Name: _________________________________________________Address: _______________________________________________City, State, Zip: _________________________________________Telephone Number: ______________________________________State Bar Number: _______________________________________Client: _________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of _________________________ ___________________________________________ CASE NO. ___________________________________, Petitioner, REQUEST AND ORDER FOR HEARING vs ___________________________________, Respondent ______________________________________________________________________________WAIV5NOTICE: 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 of Printed 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