Free Deferral Supplement - Arizona

For Clerk's Use Only

Name of Person Filing Document: Your Address: Your City, State, and Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Petitioner OR Respondent Representing

SUPERIOR COURT OF ARIZONA IN PINAL COUNTY
Case Number: Name of Petitioner/Plaintiff

Name of Respondent/Defendant

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

STATE OF ARIZONA COUNTY OF PINAL

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

The basis for the request is: 1. 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 unlikely to change in the foreseeable future.

OR
2. FURTHER DEFERRAL: a. I receive governmental assistance from the state/federal program(s) checked below: Temporary Assistance for Needy Families (TANF) Food Stamps Supplemental Security Income (SSI) General Assistance (GA) If you checked either boxes 1 or 2a., you must complete the Financial Questionnaire. You must submit proof that you receive governmental assistance. If you are submitting this application by mail or a third party, you must attach a photocopy of that proof. OR b. My income is insufficient or is barley 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:

© Superior Court of Arizona in Maricopa County May 22, 2006 ALL RIGHTS RESERVED

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Case No. 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. Although your income is greater than 150% of the poverty level, you have proof of extraordinary expenses, including medical expenses, costs of care for elderly or disabled family members or other expenses that the court finds are extraordinary and that reduce your gross monthly income to at or below 150% of the poverty level. OR

2.

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:

If you checked either boxes 2b. or 2c., you must complete the Financial Questionnaire.

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

STATEMENT OF INCOME AND EXPENSES
ASSISTANCE: I receive assistance from: Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTUS) 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: $

© Superior Court of Arizona in Maricopa County May 22, 2006 ALL RIGHTS RESERVED

GNF92f Page 2 of 3
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Case No. MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: PAYMENT AMOUNT Rent/Mortgage payment $ Car Payment $ Credit Card Payments $ $ Other payments and debts $ Explain: 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 LOAN BALANCE $ $ $ $

$

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 Other, including stocks, bonds, etc. 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: $

SIGNATURE UNDER PENALTY OF PERJURY Today's Date: Signature: Print your Name:

© Superior Court of Arizona in Maricopa County May 22, 2006 ALL RIGHTS RESERVED

GNF92f Page 3 of 3
Use current form

SWD