Case Number:  
Name of Petitioner/Plaintiff.
Name of Respondent/Defendant.


This “Application for Deferral or Waiver 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 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 step 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.

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 the penalty of prosecution for perjury if it is determined that I did not tell the truth.

I am requesting a deferral/waiver of the fee for service of process by a sheriff, marshal, constable or law enforcement agency.

The basis for the request is:

1. [  ] DEFERRAL:

A. [  ] I receive governmental assistance from the state/federal program(s) marked below:
[  ] Temporary Assistance to Needy Families (TANF)
[  ] Food Stamps (Renamed Supplemental Nutrition Assistance Program or SNAP).

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.

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 than 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.
C. [  ] 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.

2. [  ] WAIVER:

A. [  ] 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.
B. [  ] 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.

SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support and/or spousal maintenance/support for):


ASSISTANCE:  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:
Monthly gross income: $                    
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): $

      My spouse’s monthly gross income (if available to me): $


MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are:
Rent/Mortgage payment $                     $
Car Payment $                               $
Credit Card Payments $                               $
Explain: Other payments & debts $                                 $
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 Employer
or Other Retirement Account $                                


STATEMENT OF ASSETS: List only those assets available to you and accessible without financial penalty.     Equity is defined as market value minus any liens or loans.
Cash and Bank Accounts $
Credit Union Accounts $
Equity in:
1. Home $
2. Other property $
3. Cars/other vehicles $
4. Other, including stocks, bonds, etc. $
5. Retirement accounts $

TOTAL ASSETS                                                 $

EXTRAORDINARY EXPENSES: For example, unusual medical needs, financial hardship, costs of care of elderly or disabled family members.  (Proof must be submitted.)



Note: If you receive a deferral and have unpaid fees at the end of your case you will receive a Notice of Court Fees and Costs Due.  This is to remind you that you may submit a supplemental application for further deferral or waiver if you believe you need more time to pay or cannot afford to pay your court fees and costs.  The court will decide at that time whether or not you must pay.  If you do not file a supplemental application, the original deferral order remains in effect and a consent judgment may be entered against you if you do not pay within thirty calendar days after entry of final judgment.

If your case is dismissed for any reason, the fees and costs are still due.

CONSENT TO ENTRY OF JUDGMENT:  By signing this Application, I agree that a judgment may be entered against me for all fees and/or costs that are deferred but remain unpaid after 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/or costs; or,
2. Request a hearing on the court’s order denying waiver or further deferral.  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.

The contents of this document are true and correct to the best of my knowledge and belief.
Date Signature
Printed Name
Date Signed or Affirmed Judicial Officer, Deputy Clerk or Notary Public
My Commision Expires/Seal:

Please Make Note

Please make note that I, Jessica Lynn Hepner the creator of What Every Parent Should Know, is not giving legal advice. I am not a lawyer. I am giving you knowledge via first hand experiences.

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Save A Life by Angie Kassabie

Save A Life by Angie Kassabie
I URGE ALL MY FRIENDS TO READ & SHARE THIS; YOU COULD SAVE A LOVED ONES LIFE BY KNOWING THIS SIMPLE INFORMATION!!! Stroke has a new indicator! They say if you forward this to ten people, you stand a chance of saving one life. Will you send this along? Blood Clots/Stroke - They Now Have a Fourth Indicator, the Tongue: During a BBQ, a woman stumbled and took a little fall - she assured everyone that she was fine (they offered to call paramedics) ...she said she had just tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food. While she appeared a bit shaken up, Jane went about enjoying herself the rest of the evening. Jane's husband called later telling everyone that his wife had been taken to the hospital - (at 6:00 PM Jane passed away.) She had suffered a stroke at the BBQ. Had they known how to identify the signs of a stroke, perhaps Jane would be with us today. Some don't die. They end up in a helpless, hopeless condition instead. It only takes a minute to read this. A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke...totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough. >>RECOGNIZING A STROKE<< Thank God for the sense to remember the '3' steps, STR. Read and Learn! Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke. Now doctors say a bystander can recognize a stroke by asking three simple questions: S *Ask the individual to SMILE. T *Ask the person to TALK and SPEAK A SIMPLE SENTENCE (Coherently) (i.e. Chicken Soup) R *Ask him or her to RAISE BOTH ARMS. If he or she has trouble with ANY ONE of these tasks, call emergency number immediately and describe the symptoms to the dispatcher. New Sign of a Stroke -------- Stick out Your Tongue NOTE: Another 'sign' of a stroke is this: Ask the person to 'stick' out his tongue. If the tongue is 'crooked', if it goes to one side or the other that is also an indication of a stroke. A cardiologist says if everyone who gets this e-mail sends it to 10 people; you can bet that at least one life will be saved. I have done my part. Will you?

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