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FEE DEFERRAL APPLICATION (Maricopa County Telecommunications)

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FEE DEFERRAL
APPLICATION
1
To Delay Payment of Court Fees/Costs
(at the beginning of the case)
For Family Court, Tax, Civil,
Juvenile (Non-guardianship), and
Mental Health Cases
© Superior Court of Arizona in Maricopa County
ALL RIGHTS RESERVED
GNF1 – 5310 - 050119
CASE NUMBER:
Plaintiff/Petitioner
DATE:
Defendant/Respondent
DEFERRED FEE APPLICATION INFORMATION
NAME:
ADDRESS:
CITY:
STATE:
SSN:
ZIP CODE:
PHONE(H):
( )
PHONE (W):
( )
DO YOU HAVE AN ATTORNEY? YES NO
PHONE (Cell):
( )
(FOR COURT USE ONLY: Do Not Write in this Section (except for your signature, below).
FINANCIAL STATUS OF A DEFERRED FEE
FEE CODE # TYPE $
FEE CODE # TYPE $
FEE CODE # TYPE $
TOTAL AMOUNT OF FEES THAT HAVE BEEN DEFERRED: $
AMOUNT OF PARTIAL PAYMENT PAID AT TIME OF FILING: $
BALANCE: $
BALANCE OF DEFERRED FEE(S) DUE ON DAY OF , 20
I (APPLICANT) SHALL MAKE ( WEEKLY MONTHLY) PAYMENTS OF $
FINAL PAYMENT IS DUE ON OR BEFORE (BUT NO LATER THAN) THE DUE DATE ABOVE.
ANY BALANCE LEFT OUTSTANDING AFTER THE DUE DATE WILL BE SENT TO A COLLECTIONS
AGENCY.
APPLICANT SIGNATURE:
(FOR COURT USE ONLY: Do Not Write in this Section (except for your signature, below).
ASSISTANCE RECEIVED/ INCOME INFORMATION
TANF (TEMPORARY ASSISTANCE TO NEEDY FAMILIES) SSI
FOOD STAMPS < 150%
COMMUNITY LEGAL SERVICES
APPLICANT SIGNATURE:
Special
Commissioner
Complete this
section if a
payment plan
is set up.
Cross out if
deferred until
further notice.
Special
Commissioner
Check why
deferred until
further notice.
Applicant:
Special
Commissioner
Complete all
information
for each
deferred fee
in this section.
Applicant:
APPLICANT
Complete all
information
in this
section.
Page 1 of 1 GNF10f 020211
Person Filing:
Address (if not protected):
City, State, Zip Code:
Telephone:
Email Address:
Lawyer’s Bar Number:
Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent
SUPERIOR COURT OF ARIZONA
IN MARICOPA COUNTY
Case Number:
Name of Petitioner/Plaintiff
APPLICATION FOR DEFERRAL OR WAIVER
OF COURT FEES OR COSTS AND CONSENT
TO ENTRY OF JUDGMENT
Name of Respondent/Defendant
STA
TE OF ARIZONA )
COUNTY OF )
ss.
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.
For Clerk’s Use Only
© Superior Court of Arizona in Maricopa County GNF11f - 060115
ALL RIGHTS RESERVED Page 1 of 4 Use current version
ADW
Case Number: _______________
3. 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
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:
PAYMENT AMOUNT LOAN BALANCE
Rent/Mortgage payment $ $
Car payment $ $
Credit card payments $ $
Explain: ______________________________________________________________
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) $
TOTAL MONTHLY EXPENSES $
© Superior Court of Arizona in Maricopa County GNF11f - 060115
ALL RIGHTS RESERVED Page 2 of 4 Use current version
ADW
Case Number: _______________
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.
© Superior Court of Arizona in Maricopa County GNF11f - 060115
ALL RIGHTS RESERVED Page 3 of 4 Use current version
ADW
Case Number: _______________
CONSE
NT 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:
© Superior Court of Arizona in Maricopa County GNF11f - 060115
ALL RIGHTS RESERVED Page 4 of 4 Use current version
ADW
© Superior Court of Arizona in Maricopa County GNF18f - 050119
ALL RIGHTS RESERVED Page 1 of 3 Use current version
Person Filing:
Address (if not protected):
City, State, Zip Code:
Telephone:
Email Address:
Lawyer’s Bar Number:
Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent
SUPERIOR COURT OF ARIZONA
IN MARICOPA COUNTY
Case Number:
Name of Petitioner/Plaintiff
ORDER REGARDING DEFERRAL OR WAIVER
OF COURT FEES AND COSTS AND
NOTICE REGARDING CONSENT JUDGMENT
Name of Respondent/Defendant
NOTE: ONLY FILL OUT THE ABOVE INFORMATION. THE COURT WILL FILL OUT
THE REST OF THE FORM.
THE COURT FINDS that the applicant (print name) :
1. IS NOT ELIGIBLE FOR A DEFERRAL of fees and/or costs.
OR
2. IS ELIGIBLE FOR A DEFERRAL of fees and/or costs based on financial eligibility. As required by
state law, the applicant has signed a consent to entry of judgment.
OR
3. IS ELIGIBLE FOR A DEFERRAL of fees and/or costs at the court’s discretion (A.R.S. § 12-302(L)).
OR
4. IS ELIGIBLE FOR A DEFERRAL of fees and/or costs based on good cause shown. As required by
state law, the applicant has signed a consent to entry of judgment.
OR
5. IS ELIGIBLE FOR A WAIVER of fees and/or costs because the applicant is permanently unable to
pay (A.R.S. § 12-302(D)).
OR
6. IS ELIGIBLE FOR A WAIVER of fees and/or costs at the court’s discretion (A.R.S. § 12-302(L)).
OR
For Clerk’s Use Only
Case Number: _____________
© Superior Court of Arizona in Maricopa County GNF18f - 050119
ALL RIGHTS RESERVED Page 2 of 3 Use current version
ODF
7. IS NOT ELIGIBLE FOR A WAIVER of fees and/or costs.
IT IS ORDERED:
DEFERRAL IS DENIED for the following reason(s):
The application is incomplete because
You are encouraged to submit a complete application.
The applicant does not meet the financial criteria for deferral because
A deferral MUST BE granted if the applicant is receiving public assistance benefits from the
Temporary Assistance to Needy Families (TANF) program or Food Stamps; presents
documentation they are currently receiving services from a non-profit legal services
organization; has an income that is insufficient or barely sufficient to meet the daily
essentials of life and that includes no allotment that could be budgeted to pay the fees and
costs necessary to gain access to the court; or, if the applicant demonstrates other good
cause.
DEFERRAL IS GRANTED for the following fees and/or costs in this court:
Any or all filing fees; fees for the issuance of either a summons and subpoena; or the cost of
attendance at an educational program required by A.R.S. § 25-352, fees for obtaining one certified
copy of a temporary order in a domestic relations case or a final order, judgment or decree in all civil
proceedings.
Fees for service of process by a sheriff, marshal, constable or law enforcement agency.
Fees for service by publication.
Filing fees and photocopy fees for the preparation of the record on appeal.
Court reporter or transcriber fees if employed by the court for the preparation of the transcript.
IF A DEFERRAL IS GRANTED, PLEASE CHECK ONE OF THE FOLLOWING BOXES:
NO PAYMENTS WILL BE DUE UNTIL FURTHER NOTICE.
SCHEDULE OF PAYMENTS.
The applicant shall pay $ each (week, month etc.) until paid in
full, beginning .
WAIVER IS DENIED for all fees and/or costs in this case.
WAIVER IS GRANTED for all fees and/or costs in this case that may be waived under A.R.S. § 12-
302(H).
Any or all filing fees; fees for the issuance of either a summons or subpoena; or the cost of
attendance at an educational program required by A.R.S. § 25-352, fees for obtaining one
certified copy of a temporary order in a domestic relations case or a final order, judgment or decree
in all civil proceedings.
Fees for service of process by a sheriff, marshal, constable or law enforcement agency.
Case Number: _____________
© Superior Court of Arizona in Maricopa County GNF18f - 050119
ALL RIGHTS RESERVED Page 3 of 3 Use current version
ODF
Fees for service by publication.
Filing fees and photocopy fees for the preparation of the record on appeal.
Court reporter or transcriber fees if employed by the court for the preparation of the transcript.
RIGHT TO JUDICIAL REVIEW. If the application is denied or a payment schedule is set by a special
commissioner, you may request the decision be reviewed by a judicial officer. The request must be made
within twenty (20) days of the day the order was mailed or delivered to you. If a schedule of payments has
been established, payments shall be suspended until a decision is made after judicial review. Judicial review
shall be held as soon as reasonably possible.
NOTICE REGARDING CONSENT JUDGMENT. Unless any of the following applies, a consent judgment
may be entered against the applicant for all fees and costs that are deferred and remain unpaid thirty (30)
days after entry of final judgment:
A. Fees and costs are taxed to another party;
B. The applicant has an established schedule of payments in effect and is current with those payments;
C. The applicant filed 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 (20) days of the date the court denies the supplemental application, the applicant
either:
1. Pays the fees and costs; or,
2. Requests a hearing on the court’s order denying further deferral or waiver. If the applicant
requests 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.
If an appeal is taken, a consent judgment for deferred fees and costs that remain unpaid in the lower court
shall not be entered until thirty (30) days after the appeals process is concluded. The procedures for
notice of court fees and costs and for entry of a consent judgment continue to apply. If a consent judgment is
signed and the applicant pays the fees and costs in full, the court is required to comply with the provisions of
A.R.S. § 33-964(C).
DUTY TO REPORT CHANGE IN FINANCIAL CIRCUMSTANCES. An applicant who is granted a
deferral or waiver shall promptly notify the court of any change in financial circumstances during the
pendency of the case that would affect the applicant’s ability to pay court fees and costs. Any time the
applicant appears before the court on this case, the court may inquire as to the applicant’s financial
circumstances.
DATED:
Judicial Officer Special Commissioner
I CERTIFY that I mailed/delivered/provided a copy of this document to:
Applicant at the above address in court
Applicant’s attorney at the above address in court
Date: By:
Clerk
Person Filing:
Address (if not protected):
City, State, Zip Code:
Telephone:
Email Address:
Lawyer’s Bar Number:
Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent
SUPERIOR COURT OF ARIZONA
IN MARICOPA COUNTY
Case Number:
Name of Petitioner/Plaintiff
AFFIDAVIT IN SUPPORT OF APPLICATION
FOR DEFERRAL OR WAIVER OF SERVICE OF
PROCESS FEES
Name of Respondent/Defendant
STATE OF ARIZONA )
COUNTY OF )
ss.
NOTE: FILL OUT THIS FORM ONLY IF YOU REQUESTED DEFERRAL OR WAIVER OF
SERVICE COSTS IN THE APPLICATION. YOU MUST HAVE ATTEMPTED PERSONAL
SERVICE OR HAVE A VALID REASON FOR NOT DOING SO. SERVICE BY PUBLICATION
IS USED AS A LAST RESORT.
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 have requested a deferral or waiver of the following fees in my case:
[ ] Fees for service of process by a sheriff, marshal, constable, or law enforcement agency: In
support of my request, I state that (check and complete any that apply):
[ ] I have attempted to obtain voluntary acceptance of service of process without success on the person
to be served.
[ ] It would be useless or dangerous for me to try to obtain voluntary acceptance of service by the
person to be served because (explain):
[ ] An enforceable injunction against harassment has been granted to me against the person to be
served.
For Clerk’s Use Only
© Superior Court of Arizona in Maricopa County GNF21f - 090114
ALL RIGHTS RESERVED Page 1 of 2 Use current version
Case Number:
[ ] Fees for publication: In support of my request, I state that I have attempted to locate the person
to be served but I have been unable to locate that person (check and complete any that apply):
[ ] This is what I did to try to find the other party (explain):
[ ] I have contacted the person(s) listed below to try to find the location of the other party.
NAME ADDRESS
OATH OR AFFIRMATION
I declare under penalty of perjury that the foregoing is true and correct.
Date:
Signature
Applicant’s Printed Name
INFORMATION FOR SERVICE
You must provide the following information:
To the best of my knowledge, as of (date) , the last known address of the person to be
served as:
© Superior Court of Arizona in Maricopa County GNF21f - 090114
ALL RIGHTS RESERVED Page 2 of 2 Use current version
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FEE DEFERRAL APPLICATION (Maricopa County Telecommunications)

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Completed 31 July 2021

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