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Self-Help Services SUPERIOR COURT OF CALIFORNIA COUNTY OF (The Superior Court of California - County of Orange)

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SELF-HELP FORM PACKET
SHC-FW-01 (Rev. 01/01/2021)
https://www.occourts.org/se lf-help
SUPERIOR COURT OF CALIFORNIA
COUNTY OF ORANGE
Self-Help Services
www.occourts.org/self-help
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 waive some of the court fees
Family Size Family Income Family Size Family Income Family Size Family Income
1 $1,329.17 3 $2,262.50 5 $3,195.84
2 $1,795.84 4 $2,729.17 6 $3,662.50
If more than 6 people
at home, add $466.67
for each extra person.
Judicial Council of California, www.courts.ca.gov
Revised March 24, 2020, 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
✖
Case Number:
Your name:
Check here if your income changes a lot from month to month.
$
(1)
$
(2)
$
(3)
$
(4)
$
$
$
$
$
$
$
$
$
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)
$ $
(3)
$ $
(1)
$ $
(2)
$ $
(1)
$ $
(2)
$ $
(1)
$
(2)
$
(3)
$
(4)
$
$
$
$
$
$
$
$
$
$
$
(1)
$
(2)
$
(3)
$
$
(1)
$
(2)
$
(3)
$
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.
Wages/earnings withheld by court order
Any other monthly expenses (list each below).
Paid to: How Much?
Important! If your financial situation or ability to pay
court fees improves, you must notify the court within five
days on form FW-010.
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
Cars, boats, and other vehiclesc.
Fair Market
Value
How Much You
Still Owe
Make / Year
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
a.
Age
b. Total monthly income of persons above:
i. School, child care
e. Other personal property (jewelry, furniture, furs,
stocks, bonds, etc.):
Describe
Your total monthly income:b.
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.
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:
b.
m.
n.
Food and household supplies
Utilities and telephone
Medical and dental expenses
Insurance (life, health, accident, etc.)
Revised March 24, 2020
Request to Waive Court Fees
FW-001, Page 2 of 2
7
8
9
10
11
a.
Print this form
Save this form
Clear this form
For your protection and privacy, please press the Clear
This Form button after you have printed the 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:
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.
• Court fee for phone hearing
• Giving notice and certificates
• Sending papers to another court department
• Reporter’s fee for attendance at hearing or trial, if the court is not electronically recording the proceeding
and you request that the court provide an official reporter
• 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)
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 3
Judicial Council of California, www.courts.ca.gov
Revised September 1, 2019, 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
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, firm name, address,
phone number, e-mail, and State Bar number):
1
2
3
4
1
(specify): Other
(1)
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.)
Order on Court Fee Waiver (Superior Court)
FW-003, Page 2 of 3
Rev. September 1, 2019
•
•
•
b. The court denies your fee waiver request because:
•
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 incomplete items listed:
Below
On Attachment 4b(1)
Your request is incomplete. You have 10 days after the clerk gives notice of this Order (see date of service
on next page) to:
The information you provided on the request shows that you are not eligible for the fee waiver you
requested for the reasons stated:
Your name:
Case Number:
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:
The court needs more information to decide whether to grant your request. You must go to court on the
date on page 3. The hearing will be about the questions regarding your eligibility that are stated:
c.
Bring the items of proof to support your request, if reasonably available, that are listed:
Below
On Attachment 4b(2)
(1)
Below
On Attachment 4c(1)
(2)
Below
On Attachment 4c(2)
Warning! If item c(1) 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): Judicial Officer Clerk, Deputy
Date: Time:
Room:Dept.:
Hearing
Date
g
Name and address of court if different from above:
I certify that I am not involved in this case and (check one):
Clerk's Certificate of Service
I handed a copy of this Order to the party and attorney, if any, listed in and , at the court, on the date below.
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.
A certificate of mailing is attached.
1 2
(city):
1 2
Your name:
Case Number:
Order on Court Fee Waiver (Superior Court)
FW-003, Page 3 of 3
Rev. September 1, 2019
This is a Court Order.
Request for Accommodations
Assistive listening systems, computer-assisted real-time captioning, or sign language interpreter services
are available if you ask at least five days before the hearing. Contact the clerk’s office for Request for
Accommodations by Persons With Disabilities and Response (form MC-410). (Civ. Code, § 54.8.)
, Deputy
Clerk, by ________________________________
Name:
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Self-Help Services SUPERIOR COURT OF CALIFORNIA COUNTY OF (The Superior Court of California - County of Orange)

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Completed 8 February 2021

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