Fillable AJO JUSTICE COURT 111 La Mina Avenue Ajo, (Pima County Government)

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AJO JUSTICE COURT 111 La Mina Avenue Ajo, (Pima County Government)

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AJO JUSTICE COURT – 111 La Mina Avenue – Ajo, Arizona 85321 – (520) 387-7684
Name of Person Filing Document:
Your Address:
Your City, State, and Zip Code:
Your Telephone Number:
Attorney Bar Number (if applicable):
Attorney E-mail Address:
Representing Self (Without an Attorney) OR
Attorney for
Petitioner Respondent
STATE OF ARIZONA )
COUNTY OF )
ss.
Name of Petitioner/Plaintiff
Case Number:
APPLICATION FOR DEFERRAL OR WAIVER
OF COURT FEES OR COSTS AND CONSENT
TO ENTRY OF JUDGMENT
Name of Respondent/Defendant
Notice. A Fee Deferral is only a temporary postponement of the payment of the fees due. You may be
required to make payments depending on your income. A Fee Waiver is usually permanent unless your
financial circumstances change during the pendency of this court action.
I am requesting a deferral or waiver of all fees including: filing a case, issuance of a summons or subpoena,
the cost of attendance at an educational program required by A.R.S. § 25-352, one certified copy of a
temporary order in a family law case, one certified copy of the court’s final order, preparation of the record
on appeal, court reporter’s fees of reporters or transcribers, service of process costs, and/or service by
publication costs. (I have completed the separate Supplemental Information form if I am asking for service
of process costs, or service by publication costs.) I understand that if I request deferral or waiver because I
am a participant in a government assistance program, I am required to provide proof at the time of filing.
The document(s) submitted must show my name as the recipient of the benefit and the name of the agency
awarding the benefit. Note. All other applicants must complete the financial questionnaire beginning
at section 3. If you are a participant in one of the programs in section 1 or
2 (below), you do not need to complete the financial questionnaire, and can proceed to the signature
page.
1. [ ] DEFERRAL: I receive government assistance from the state or federal program marked below or
am represented by a not for profit legal aid program:
[ ] Temporary Assistance to Needy Families (TANF)
[ ] Food Stamps
[ ] Legal Aid Services
2. [ ] WAIVER:
[ ] I receive government assistance from the federal Supplemental Security Income (SSI)
program.
3. FINANCIAL QUESTIONNAIRE
PAYMENT AMOUNT
LOAN BALANCE
Rent/Mortgage payment
$
$
Car payment
$
$
Credit card payments
$
$
n:Other payments & debts
$
$
Household
$
Utilities/Telephone/Cable
$
Medical/Dental/Drugs
$
Health insurance
$
Nursing care
$
Tuition
$
Child support
$
Child care
$
Spousal maintenance
$
Car insurance
$
Transportation
$
Other expenses (explain)
$
SUPPORT RESPONSIBILITIES. List all persons you support (including those you pay child support
and/or spousal maintenance/support for):
NAME RELATIONSHIP
STA
TEMENT OF INCOME AND EXPENSES
Employer name:
Employer phone number:
[ ] I am unemployed (explain):
My prior year’s gross income: $
MONTHLY INCOME
My total monthly gross income: $
My spouse’s monthly gross income (if available to me):
Other $
current monthly income, including spousal
maintenance/support, retirement, rental, interest, pensions, and
lottery winnings:
$
TOTAL MONTHLY INCOME $
MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are:
Explain
TOT
AL MONTHLY EXPENSES $
STATEMENT OF ASSETS: List only those assets available to you and accessible without financial
penalty.
ESTIMATED VALUE
Cash and bank accounts $
Credit union accounts
$
Other liquid assets
$
TOTAL ASSETS $
$
The basis for the request is:
4. [ ] DEFERRAL:
A. [ ] 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. My gross income as computed on a monthly basis is 150% or less of the current federal
poverty level. (Note: Gross monthly income includes your share of community property income if
available to you.)
OR
B. [ ] 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.
OR
C. [ ] My income is greater than 150% of the poverty level, but have proof of extraordinary
expenses (including medical expenses and costs of care for elderly or disabled family members)
or other expenses that reduce my gross monthly income to 150% or below the poverty level.
DESCRIPTION OF EXPENSES
AMOUNT
$
$
$
TOTAL EXTRAORDINARY EXPENSES
$
5. [ ] 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 are unlikely to change in the foreseeable future.
IMPORTANT
This “Application for Deferral or Waiver of Court Fees 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 steps you must take to avoid a judgment against you if you are still participating in
a qualifying program. You may be ordered to repay any amounts that were waived if the court finds
you were not eligible for the fee deferral or waiver. 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 or costs that are deferred but remain unpaid thirty (30) calendar days after entry of
final judgment.
OATH OR AFFIRMATION
I declare under penalty of perjury that the foregoing is true and correct.
Date
Signature
Applicant’s Printed Name
Date
Judicial Officer, Deputy Clerk or Notary Public
__________________________
My Commission Expires/Seal:
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AJO JUSTICE COURT 111 La Mina Avenue Ajo, (Pima County Government)

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Completed 14 February 2021

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