Arizona > Local County > Maricopa > Superior Court > Probate
Application For Deferral Or Waiver Of Court Fees And Costs PBW11f - Arizona
| Application For Deferral Or Waiver Of Court Fees And Costs Form. This is a Arizona form and can be used in Probate Superior Court Maricopa Local County . |
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Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Self or Attorney for Representing FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Name of Petitioner/Plaintiff Case Number: APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND COSTS and CONSENT TO ENTRY of JUDGMENT ) ) ss Name of Respondent/Defendant STATE OF ARIZONA COUNTY OF STATEMENTS MADE TO THE COURT UNDER OATH OR BY AFFIRMATION: I swear or affirm that the information in this application is true and correct. 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 or waiver 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): © Superior Court of Arizona in Maricopa County June 23, 2010 ALL RIGHTS RESERVED Page 1 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkFlow.com APD Case No. 3. The basis for the deferral request is A. I or the Estate/Ward/Protected Person receive governmental assistance from the state/federal program(s) checked below: Temporary Assistance to Needy Families (TANF) Represented by Community Legal Services Food Stamps OR B. 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. 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. 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. 2. C. 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. OR 2. A. The basis for the waiver request is: 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. I receive government assistance from the federal program Supplemental Security Income (SSI). B. NOTE: Every applicant, regardless of his or her financial circumstances, must complete the Financial Questionnaire that follows. · · · · If you submit the Application and Questionnaire in person, you MUST sign it in front of the court clerk; If you submit the form by mail or by a third party, you MUST sign it in front of a notary public. You must submit proof that you receive governmental assistance. If you submit the Application and Financial Questionnaire by mail or by a third party, please attach a copy of your proof of governmental assistance. Page 2 of 5 © Superior Court of Arizona in Maricopa County June 23, 2010 ALL RIGHTS RESERVED PBW11f Use current form American LegalNet, Inc. www.FormsWorkFlow.com APD Case No. FINANCIAL QUESTIONNAIRE STATEMENT OF INCOME AND EXPENSES: SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support and/or spousal maintenance/support for): NAME RELATIONSHIP ASSISTANCE: I receive assistance from: Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTCS) Other: (Explain/Describe) EMPLOYER INFORMATION Employer Name: Employer Address: Employed since: MONTHLY INCOME INFORMATION Monthly Gross Income: (full amount of wages/salary before any deductions) Other current monthly income: (including spousal maintenance/support, retirement, rental, interest, pensions, scholarships, grants, royalties, lottery winnings) (explain amount and source) $ (Month and Year you started) $ $ $ My spouse's monthly gross income: (if available to me) $ TOTAL MONTHLY INCOME: (Add amounts from these lines.) $ © Superior Court of Arizona in Maricopa County June 23, 2010 ALL RIGHTS RESERVED Page 3 of 5 PBW11f Use current form American LegalNet, Inc. www.FormsWorkFlow.com APD My monthly expenses and debts are: Rent/Mortgage payment Car Payment Car Payment Credit Card Payments Credit Card Payments $ $ $ $ $ A MONTHLY PAYMENT $ $ $ $ $ $ $ $ B LOAN BALANCE Other Financing Obligations with Monthly Payments: $ Describe: $ Describe: $ Describe: TOTAL OF LOAN BALANCES: (Add column B) $ Food/Household supplies Clothing Utilities (Electric, Gas, Water, Telephone) Medical / Dental/ Prescription Expenses Health Insurance Car Insurance Gasoline/Bus Fare Spousal Maintenance (alimony paid by you) Child Support Child Care Nursing care Contributions to Retirement Plan / Account Other Ot
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