How to File a Fee Waiver
Revised 09/25/2018, CN 11208 page 4 of 8
Instructions for Completing Form A - Certification/Petition/Application
in Support of a Fee Waiver
1. At the top left of the form enter your name(s), address(es) and phone number(s). If you have an e-mail
address(es), include that as well.
2. On the line labeled Plaintiff(s)/Appellant(s), type or print the plaintiff’s name(s). The plaintiff is the person or
business entity who files the complaint in a lawsuit. An appellant is the person or business entity requesting
the appeal. Business entities requesting a fee waiver are required to be represented by an attorney pursuant to
3. On the line labeled Defendant(s)/Respondent(s), enter the name(s) of the defendants listed on the complaint.
The defendant is the person or business entity being sued. A respondent is the person defending the appeal.
4. On the line labeled County, enter the county where the case is filed (only if applying for a fee waiver in the
5. On the line labeled Docket Number, enter the docket number, if one has been assigned. This information can
be found if a complaint was served on you or if an appeal has been filed.
6. Enter your name(s) on the line that says “I/We, , am/are the” and then select the appropriate box where
it says “plaintiff(s)/appellant(s)/defendant(s)/respondent(s) in the above-captioned matter.”
7. In item #2, select the appropriate box as to whether or not you are an inmate on the line that says “I/We
(am/am not/are/are not) an inmate in State prison or County Jail.”
8. For item #3, select the appropriate box(es) if you have been determined eligible for Public Assistance and/or
Social Security Disability. You must provide your most recent award statement as proof of eligibility.
Attach copies of all requested information as indicated on this form. You must include the last three digits or
numbers of any documents referenced below. However, you must also certify that you have removed or
blacked out the remaining numbers or digits (confidential personal identifiers) from any of the following
documents filed with the court:
• Social Security numbers,
• driver’s license numbers,
• vehicle plate numbers,
• insurance policy numbers,
• active financial account numbers
• active credit card numbers or
• military status.
Do not redact (black out) any information in the original papers that you are keeping (such as a bank
statement) since you may have to show them to the court at some point.
9. For item #4, enter the number of dependents you support, if applicable. Do not include yourself.
10. In item #5, select the box where is says “I/we am/am not/are/are not claimed as a dependent…”.
11. Enter your employer’s name and information in the box that says “Employer’s Name, Address and Telephone
12. Fill in the financial information requested in the box. The judge requires your asset information and how
much money you receive monthly from all sources.
13. Date, print and sign your name. Note: When you sign this form, you are certifying that the statements made
on the form are true. If you willfully make false statements, you may be subject to punishment.