Fillable FeeWaiverApplication FW-001 July 2 Revision.ofm

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FeeWaiverApplication FW-001 July 2 Revision.ofm

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If you are getting public benefits, are a low-income person, or do not have
enough income to pay for your household’s basic needs and your court fees, you
may use this form to ask the court to waive your court fees. The court may order
you to answer questions about your finances. If the court waives the fees, you
may still have to pay later if:
• You cannot give the court proof of your eligibility,
• Your financial situation improves during this case, or
• You settle your civil case for $10,000 or more. The trial court that waives
your fees will have a lien on any such settlement in the amount of the
waived fees and costs. The court may also charge you any collection costs.
Your Information (person asking the court to waive the fees):
Name:
Street or mailing address:
State: Zip:City:
Phone number:
Your Job, if you have one (job title):
Employer’s address:
The lawyer has agreed to advance all or a portion of your fees or costs (check one):
(If yes, your lawyer must sign here) Lawyer’s signature:
Why are you asking the court to waive your court fees?
b.
Name of employer:
If your lawyer is not providing legal-aid type services based on your low income, you may have to go to a
hearing to explain why you are asking the court to waive the fees.
Your Lawyer
, if you have one (name, firm or affiliation, address, phone number, and State Bar number):
What court’s fees or costs are you asking to be waived?
I declare under penalty of perjury under the laws of the State of California that the information I have provided
on this form and all attachments is true and correct.
a.
b.
Yes No
Superior Court (See Information Sheet on Waiver of Superior Court Fees and Costs (form FW-001-INFO).)
Supreme Court, Court of Appeal, or Appellate Division of Superior Court (See Information Sheet on Waiver
of Appellate Court Fees (form APP-015/FW-015-INFO).)
My gross monthly household income (before deductions for taxes) is less than the amount listed below. (If
you check 5b, you must fill out 7, 8, and 9 on page 2 of this form.)
Check here if you asked the court to waive your court fees for this case in the last six months.
(If your previous request is reasonably available, please attach it to this form and check here:)
a.
I receive (check all that apply; see form FW-001-INFO for definitions):
Medi-Cal
Food Stamps
SSP
Supp. Sec. Inc.
County Relief/Gen. Assist. IHSS CalWORKS or Tribal TANF CAPI
c.
I do not have enough income to pay for my household’s basic needs and the court fees. I ask the court to:
(check one and you must fill out page 2):
let me make payments over time
waive all court fees and costs
Family Size Family Income Family Size Family Income Family Size Family Income
1 $1,256.26 3 $2,127.09 5 $2,997.92
2 $1,691.67 4 $2,562.51 6 $3,433.34
If more than 6 people
at home, add $435.42
for each extra person.
Judicial Council of California, www.courts.ca.gov
Revised March 1, 2017, Mandatory Form
Government Code, § 68633
Cal. Rules of Court, rules 3.51, 8.26, and 8.818
Request to Waive Court Fees
FW-001, Page 1 of 2
Sign here
Print your name here
Date:
1
2
3
4
5
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Fill in case number and name:
Case Number:
Case Name:
CONFIDENTIAL
6
FW-001
Request to Waive Court Fees
waive some of the court fees
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
end of the form when finished.
✔
If you checked 5a on page 1, do not fill out below. If you checked 5b, fill out questions 7, 8, and 9 only.
If you checked 5c, you must fill out this entire page. If you need more space, attach form MC-025 or attach a
sheet of paper and write Financial Information and your name and case number at the top.
Your Money and Property
Cash
All financial accounts (List bank name and amount):
(1)
$
Your Gross Monthly Income
(2)
$
List any payroll deductions and the monthly amount below:
(3)
$
$
(1)
(2)
$
Cars, boats, and other vehiclesc.
$
(3)
Fair Market
Value
How Much You
Still Owe
(4)
$
Make / Year
(1)
$ $
(2)
$ $
List the source and amount of any income you get each month,
including: wages or other income from work before deductions,
spousal/child support, retirement, social security, disability,
unemployment, military basic allowance for quarters (BAQ),
veterans payments, dividends, interest, trust income, annuities,
net business or rental income, reimbursement for job-related
expenses, gambling or lottery winnings, etc.
a.
Real estated.
Fair Market
Value
How Much You
Still OweAddress
(1)
$ $
(2)
$ $
(1)
$
e. Other personal property (jewelry, furniture, furs,
stocks, bonds, etc.):
(2)
$
(3)
$
(4)
$
Describe
(1)
$ $
Your total monthly income:b.
$
(2)
$ $
$ $
(3)
Household Income
Your Monthly Deductions and Expenses
List the income of all other persons living in your home who
depend in whole or in part on you for support, or on whom you
depend in whole or in part for support.
Gross Monthly
Income
b. Rent or house payment & maintenance
$
RelationshipName
c.
$
(1)
$
d.
$
(2)
$
e. Clothing
$
(3)
$
f. Laundry and cleaning
$
(4)
$
g.
$
$
b. Total monthly income of persons above:
i. School, child care
$
$
Child, spousal support (another marriage)j.
Total monthly income and
household income (8b plus 9b):
Transportation, gas, auto repair and insurance k.
$
l.
Installment payments (list each below):
Paid to:
(1)
$
(2)
$
(3)
Wages/earnings withheld by court order
Any other monthly expenses (list each below).
Paid to:
How Much?
(1)
$
Important! If your financial situation or ability to pay
court fees improves, you must notify the court within five
days on form FW-010.
(2)
$
(3)
$
Total monthly expenses (add 11a –11n above):
$
If it does, complete the form based on your average income for
the past 12 months.
a.
h.
$
$
Fair Market
Value
How Much You
Still Owe
$
$
a.
Age
b.
m.
n.
Food and household supplies
Utilities and telephone
Medical and dental expenses
Insurance (life, health, accident, etc.)
$
Check here if your income changes a lot from month to month.
Case Number:
Your name:
Revised March 1, 2017
Request to Waive Court Fees
FW-001, Page 2 of 2
7
8
9
10
11
To list any other facts you want the court to know, such as
unusual medical expenses, etc., attach form MC-025 or
attach a sheet of paper and write Financial Information and
your name and case number at the top.
Check here if you attach another page.
$
a.
For your protection and privacy, please press the Clear
This Form button after you have printed the form.
Print This Form
Clear This Form
A request to waive court fees was filed on (date):
Read this form carefully. All checked boxes are court orders.
þ
(1)
Fee Waiver. The court grants your request and waives your court fees and costs listed below. (Cal.
Rules of Court, rules 3.55 and 8.818.) You do not have to pay the court fees for the following:
• Giving notice and certificates
• Sending papers to another court department
• Court-appointed interpreter in small claims court
• Reporter’s fee for attendance at hearing or trial, if reporter provided by the court
• Assessment for court investigations under Probate Code section 1513, 1826, or 1851
• Preparing, certifying, copying, and sending the clerk’s transcript on appeal
• Holding in trust the deposit for a reporter's transcript on appeal under rule 8.130 or 8.834
• Making a transcript or copy of an official electronic recording under rule 8.835
(2)
Additional Fee Waiver. The court grants your request and waives your additional superior court fees
and costs that are checked below. (Cal. Rules of Court, rule 3.56.) You do not have to pay for the
checked items.
Jury fees and expenses Fees for a peace officer to testify in court
Court-appointed interpreter fees for a witness
Fees for court-appointed experts
Order on Court Fee Waiver (Superior Court)
FW-003, Page 1 of 2
Judicial Council of California, www.courts.ca.gov
Revised July 1, 2015, Mandatory Form
Government Code, § 68634(e)
Cal. Rules of Court, rule 3.52
• Filing papers in Superior Court
• Making copies and certifying copies
• Sheriff ’s fee to give notice
• Court fee for phone hearing
Person who asked the court to waive court fees:
Notice: The court may order you to answer questions about your finances and later order you to pay back the waived
fees. If this happens and you do not pay, the court can make you pay the fees and also charge you collection fees. If there
is a change in your financial circumstances during this case that increases your ability to pay fees and costs, you must
notify the trial court within five days. (Use form FW-010.) If you win your case, the trial court may order the other side
to pay the fees. If you settle your civil case for $10,000 or more, the trial court will have a lien on the settlement in the
amount of the waived fees. The trial court may not dismiss the case until the lien is paid.
a.
The court grants your request, as follows:
Name:
Street or mailing address:
City:
State:
Zip:
The court made a previous fee waiver order in this case on (date):
FW-003
Order on Court Fee Waiver
(Superior Court)
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Fill in case number and name:
Case Number:
Case Name:
Request to Waive Court Fees
Request to Waive Additional Court Fees
After reviewing your:
the court makes the following orders:
Lawyer, if person in has one (name, address, phone number,
e-mail, and State Bar number):
1
2
3
4
1
(specify): Other
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
end of the form when finished.
(1)
The court denies your request because it is incomplete. You have 10 days after the clerk gives notice of
this order (see date of service on next page) to:
Pay your fees and costs, or
(2)
Pay your fees and costs in full or the amount listed in c. below, or
Ask for a hearing in order to show the court more information. (Use form FW-006 to request
hearing.)
The court needs more information to decide whether to grant your request. You must go to court on the date
below. The hearing will be about (specify questions regarding eligibility):
c.
Bring the following proof to support your request if reasonably available:
Warning! If item c is checked, and you do not go to court on your hearing date, the judge will deny your
request to waive court fees, and you will have 10 days to pay your fees. If you miss that deadline, the
court cannot process the court papers you filed with your request. If the papers were a notice of appeal,
the appeal may be dismissed.
Date:
Signature of (check one):
Order on Court Fee Waiver (Superior Court)
FW-003, Page 2 of 2
Revised July 1, 2015
•
•
•
b. The court denies your fee waiver request, as follows:
•
Warning! If you miss the deadline below, the court cannot process your request for hearing or the court papers
you filed with your original request. If the papers were a notice of appeal, the appeal may be dismissed.
File a new revised request that includes the items listed below (specify incomplete items):
Judicial Officer Clerk, Deputy
The court denies your request because the information you provided on the request shows that you are
not eligible for the fee waiver you requested (specify reasons):
Your name:
Case Number:
Date: Time:
Room:Dept.:
Hearing
Date
g
Name and address of court if different from above:
This is a Court Order.
The court has enclosed a blank Request for Hearing About Court Fee Waiver Order (Superior Court),
form FW-006.You have 10 days after the clerk gives notice of this order (see date of service below) to:
Request for Accommodations. Assistive listening systems, computer-assisted real-time captioning, or sign
language interpreter services are available if you ask at least 5 days before your hearing. Contact the clerk’s
office for Request for Accommodation, Form MC-410. (Civil Code, § 54.8.)
I certify that I am not involved in this case and (check one):
Clerk's Certificate of Service
This order was mailed first class, postage paid, to the party and attorney, if any, at the addresses listed in and ,
from
Date:
, California on the date below.
Clerk, by , Deputy
A certificate of mailing is attached.
I handed a copy of this order to the party and attorney, if any, listed in and , at the court, on the date below.
1 2
(city):
1 2
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Completed 3 July 2020

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