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 courts 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
$1,264.59
3
$2,164.59
5
$3,064.59
2
$1,714.59
4
$2,614.59
6
$3,514.59
If more than 6 people
at home, add $450.00
for each extra person.
Judicial Council of California,
www.courts.ca.gov
Revised March 2, 2018, 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
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 2, 2018
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.
0
0
0
0
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