Supplemental Application For Waiver Or Further Deferral Of Court Fees And Costs
Download a blank fillable Supplemental Application For Waiver Or Further Deferral Of Court Fees And Costs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Supplemental Application For Waiver Or Further Deferral Of Court Fees And Costs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Print Form
Pinal County Justice Courts, State of Arizona
SELECT A COURT FROM THE DROP DOWN ARROW AT RIGHT >>>>>>
SUPPLEMENTAL APPLICATION FOR WAIVER OR
FURTHER DEFERRAL OF COURT FEES AND COSTS
Case Number: ___________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Plaintiff(s)
Name / Address / Phone
Defendant(s)
Name / Address / Phone
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.
STATE OF ARIZONA )
ss
COUNTY OF PINAL
)
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.
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
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.
2.
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
c.
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: ________________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________________
11-0120
Revised: 08/15/08
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal