Maricopa County Justice Courts, State of Arizona
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Case Number: Name of Petitioner/Plaintiff SUPPLEMENTAL APPLICATION FOR WAIVER OR FURTHER DEFERRAL OF COURT FEES AND COSTS Name of Respondent/Defendant STATE OF ARIZONA COUNTY OF MARICOPA ) ss )
STATEMENTS MADE TO THE COURT UNDER OATH. 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 waiver or further deferral 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. FURTHER DEFERRAL: a. I receive governmental assistance from the state/federal program(s) checked below: Temporary Assistance for Needy Families (TANF) Supplemental Security Income (SSI) Food Stamps General Assistance (GA)
If you checked either boxes I 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 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.
Although your income is greater than 150% of the poverty level, 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 I do not have the money to pay the court fees and costs now. I can pay the fees and 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 paying child support and spousal maintenance): RELATIONSHIP NAME
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, retirement, rental, interest, pensions, dividends, 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 $ $ Other payments & 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 $
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 $ $ $ TOTAL EXTRAORDINARY EXPENSES SIGNATURE UNDER PENALTY OF PERJURY Today's Date: Signature: Print Your Name: $ AMOUNT