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
FW-001
Request to Waive Court Fees
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:
Your Job, if you have one (job title):
Name of employer:
Employer’s address:
Your Lawyer
, if you have one (name, firm or affiliation, address, phone number, and State Bar number):
No Yes
(If yes, your lawyer must sign here) Lawyer’s signature:
The lawyer has agreed to advance all or a portion of your fees or costs (check one):
Why are you asking the court to waive your court fees?
b.
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.
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.
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 $1,301.05 3 $2,221.88 5 $3,142.71
2 $1,761.46 4 $2,682.30 6 $3,603.13
If more than 6 people
at home, add $460.42
for each extra person.
Judicial Council of California, www.courts.ca.gov
Revised March 15, 2019, 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
6
waive some of the court fees
CONTRA COSTA
751 PINE STREET
P.O. BOX 911
MARTINEZ, CA 94553
11 MAIN STREET, WALNUT CREEK, CA
