Tuesday, October 23, 2012

SUPPLEMENTAL APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS


(COURT’S JURISDICTIONAL NAME AND ADDRESS HERE)


                            Case Number:  
Name of Petitioner/Plaintiff.
SUPPLEMENTAL APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS
                                                     
Name of Respondent/Defendant.

STATE OF ARIZONA         )
COUNTY OF ) 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 the penalty of prosecution for perjury if it is determined that I did not tell the truth.

I am requesting a deferral/waiver of any unpaid fees and/or costs in my case.

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

OR
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.
OR
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.

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

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:  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): $

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 $                                 $
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 $                                

TOTAL MONTHLY PAYMENTS $

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.
ESTIMATED VALUE
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.)

DESCRIPTION AMOUNT
                                                                            $
                                                                            $
                                                                            $

TOTAL EXTRAORDINARY EXPENSES $


OATH OR AFFIRMATION
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: