Tempe Municipal Court

140 East Fifth Street

Tempe, AZ 85281

Requested By:

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Requested By:

Case Number(s):

Name (First, Middle, Last):

Date of Birth:

Social Security #:

Driver's License #:

Mailing Address:

Apartment/Unit:

City:

State:

Zip:

Cell Phone:

Email Address:

In addition to yourself, how many other dependents do you support?

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INCOME (Monthly): List all household income

 *

INCOME (Monthly): List all household income

Self: Wages, Salaries, Self-Employment Income

Other:

Total Income:

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EXPENSES: List all expenses

 *

EXPENSES: List all expenses

Rent or house payment:

Utilities - water, electric, gas, phone

Other Financial Obligations

Total Expenses:

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NOTICE
The Court will refer outstanding and delinquent balances to a collection agency and notify the Arizona Department of Revenue (ADOR) to take any legally appropriate collection action.

COMMENTS:

COMMENTS:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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