Application For Deferral Or Waiver Of Court Fees And Costs And Consent To Entry Of Judgment
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Pinal County Justice Courts, State of Arizona
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APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND COSTS
AND CONSENT TO ENTRY OF JUDGMENT
Case Number: ___________________________
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Plaintiff(s)
Name / Address / Phone
Defendant(s)
Name / Address / Phone
IMPORTANT
This Application for Deferral of Court Fees and 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 unable to pay. Additional details about this process are
discussed in the Consent to Entry of Judgment section of this application.
STATE OF ARIZONA
)
ss
COUNTY OF PINAL
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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 deferral or waiver of the following fees and costs in my case:
Any or all of the following: All filing fees; fees for the issuance of either a summons and subpoena; or 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 (fill out separate affidavit form).
Fees for service by publication (fill out separate affidavit form).
Filing fees and photocopy fees for the preparation of the record on appeal.
Court reporter’s fees of reporters or transcribers employed by the court for the preparation of the transcript.
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.
2.
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)
for disabilities
If you checked either boxes 1 or 2a, you must complete the Financial Questionnaire. You must sign this
application in front of the court clerk, or a notary public if submitted by mail or third party. You must also
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
Page 1 of 4
11-0118
Revised: 08/08/2008
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