COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): RepresentingJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Self (Without Attorney) ORAttorney forPetitioner ORRespondentSUPERIOR COURT OF ARIZONA MARICOPA COUNTY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Case Number Name of Petitioner/PlaintiffSUPPLEMENTAL APPLICATION FOR WAIVER OR FURTHER DEFERRAL Name of Respondent/DefendantTHE PEOPLE OF THE STATE OF NEW YORK TOOF COURT FEES AND/OR COSTSSTATE OF ARIZONA)COUNTY OF MARICOPA) ssGREETINGS: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. 1.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomI am requesting a waiver or further deferral of any unpaid 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.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.OR 2.FURTHER DEFERRAL: a., one of the Justices of theI receive governmental assistance from the state/federal program(s) checked below: Temporary Assistance for Needy Families (TANF)Food Stamps Supplemental Security Income (SSI)Court in Witness, Honorableday of, 20 County,General Assistance (GA)If you checked either boxes 1 or 2a., you must complete the Financial Questionnaire. You must submit proof that you receive governmental assistance. If you are submitting this application by mail or a third party, you must attach a photocopy of that proof.(Attorney must sign above and type name below)Attorney(s) forORb.My income is insufficient or is barley 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.Office and P.O. AddressNOTE: 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:Telephone No.: Facsimile No.: E-Mail Address:© Superior Court of Arizona in Maricopa CountyGNF92f July 16, 2002Mobile Tel. No.:Page 1 of 3Use current form ALL RIGHTS RESERVED SWDAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)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.Although your income is greater than 150% of the poverty level, 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.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ORc.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. ExplainTHE PEOPLE OF THE STATE OF NEW YORK TOIf you checked either boxes 2b. or 2c., you must complete the Financial Questionnaire.GREETINGS:FINANCIAL QUESTIONNAIREWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableSUPPORT RESPONSIBILITIES: List all persons you support (including those for whom you pay child support and/or spousal maintenance/support): NAME,located at County ofRELATIONSHIPo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.STATEMENT OF INCOME AND EXPENSESASSISTANCE: I receive assistance from: Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTUS) Other (explain): MONTHLY INCOME: My monthly income is: Monthly gross income:, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)$ Employer name: Employer address: Employed since (month/year): Other current monthly income, including spousal Maintenance/support, retirement, rental, interest, pensions, scholarships, grants, royalties, lottery winnings (explain amount and source):Attorney(s) for$Office and P.O. AddressMy spouse's monthly gross income (if available to me): $TOTAL MONTHLY INCOME:$Telephone No.: Facsimile No.: E-Mail Address:© Superior Court of Arizona in Maricopa CountyGNF92f July 16, 2002Mobile Tel. No.:Page 2 of 3Use current form ALL RIGHTS RESERVED SWDAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are:PAYMENT AMOUNTLOAN BALANCE Rent/Mortgage payment$$ Car Payment$$ Credit Card Payments$$ Other payments and debts$$ Explain:Food/Household supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ Utilities/Telephone$ Clothing$ Medic
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