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PIMA COUNTY CONSOLIDATED JUSTICE COURT 240 North Stone (Pima County Government)

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JP703 – September 2014 AOC (Updated 02/13/2019)
PIMA COUNTY CONSOLIDATED JUSTICE COURT
240 North Stone Avenue Tucson, AZ 85701 (520) 724-3171
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
Case Number:
Name of Petitioner/Plaintiff
APPLICATION FOR DEFERRAL OR WAIVER
OF SERVICE OF PROCESS FEE FOR
INJUNCTIONS AGAINST HARASSMENT AND
CONSENT TO ENTRY OF JUDGMENT
Name of Respondent/Defendant
ST
ATE OF ARIZONA )
COUNTY OF )
ss.
No
tice. 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/waiver of the fee for service of process by a sheriff, marshal, constable or
law enforcement agency. 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. [ ] W
AIVER
:
[ ] I
receive government assistance from the federal Supplemental Security Income (SSI) program.
3. FI
NANCIAL QUESTIONNAIRE
SUPPORT RESPONSIBILITIES: List all persons you support (including those you pay child support
JP703 – September 2014 AOC (Updated 02/13/2019)
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 $
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 $
JP703 – September 2014 AOC (Updated 02/13/2019)
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 Service of Process for Injunctions against Harassment” 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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PIMA COUNTY CONSOLIDATED JUSTICE COURT 240 North Stone (Pima County Government)

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Completed 13 April 2021

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