Supplemental Application For Waiver Or Further Deferral Of Court Fees And Costs Page 2
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If you checked either boxes 2b or 2c, 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 a third party.
FINANCIAL QUESTIONNAIRE
SUPPORT RESPONSIBILITIES: List all persons you support (including paying child support and spousal maintenance):
NAME
RELATIONSHIP
______________________________
____________________________
______________________________
___________________________
______________________________
___________________________
______________________________
___________________________
STATEMENT OF INCOME AND EXPENSES
ASSISTANCE: I receive assistance from:
Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Case 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
$ ________________
Nursing care
$ ________________
Laundry
$ ________________
Child support
$ ________________
Child care
$ ________________
Spousal maintenance
$ ________________
Car insurance
$ ________________
Gasoline/Bus fare
$ ________________
Retirement/Deferred comp.
$ ________________
TOTAL MONTHLY PAYMENTS
$ _______________
11-0120
Revised: 08/15/08
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