Arizona > Local County > Pima > Superior Court > Family Law
Application For Deferral Or Waiver Of Court Fees And Or Costs And Consent - Arizona
| Application For Deferral Or Waiver Of Court Fees And Or Costs And Consent Form. This is a Arizona form and can be used in Family Law Superior Court Pima Local County . |
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Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY ______________________________________________ Petitioner/Plaintiff and Case No. _________________ ______________________________________________ Respondent/Defendant APPLICATION FOR DEFERRAL/ WAIVER OF COURT FEES AND/ OR COSTS AND CONSENT TO ENTRY OF JUDGMENT IMPORTANT This "Application for Deferral of Court Fees and/or Costs" includes a "Consent to Entry of Judgment." By signing this Consent, you agree a judgment may be entered against you for all fees and costs that are deferred but remain unpaid after thirty (30) calendar days after 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 if you are still unable to pay. Additional details about this process are discussed in the "Consent to Entry of Judgment" section of this application. STATE OF ARIZONA COUNTY OF PIMA ) )ss ) STATEMENTS MADE TO THE COURT UNDER OATH OR AFFIRMATION. I swear or affirm that the information in this application is true and correct. I make this statement under 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/or costs in my case: Any or all of the following: All filing fees, fees for issuance of either a summons and subpoena, or 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. ยง 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 preparation of the record on appeal. Court reporter's fees of reporters or transcribers employed by the court for the preparation of the transcript. deferral-cover sheet.form Revised 01.08.13 1 American LegalNet, Inc. www.FormsWorkFlow.com The basis for the request is: 1. DEFERRAL (please check one of the following reasons to explain why you need a deferral): I receive governmental assistance from the state/federal program(s) marked below: Temporary Assistance to Needy Families (TANF) Food Stamps OR 2. 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. 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. If your income is greater that 150% of the poverty level, but you have proof of extraordinary expenses (including medical expenses and 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 3. 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: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ WAIVER (please check one of the following reasons to explain why your fees should be waived): 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. 1. OR 2. I receive government assistance from the federal program Supplemental Security Income (SSI). NOTE: Every applicant, regardless of his or her financial circumstances, must complete the Financial Questionnaire (below). If you submit the Application and Financial 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. deferral-cover sheet.form Revised 01.08.13 2 American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support and/or spousal maintenance for): NAME _________________________________________ _________________________________________ _________________________________________ RELATIONSHIP _______________________________________ _______________________________________ _______________________________________ 1. 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: Employer's name: __________________________________________________ Employer's address: __________________________________________________ Employed since (month/year): ____________________ 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: 2. MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: PAYMENT AMOUNT $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ___________ Rent/Mortgage Payment Car Payment Credit Card Payments Explain: Other Payments & Debts: Explain: Food/Household Supplies Utilities/Telephone C
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