Fw 001 Application For Waiver Of Court Fees And Costs
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1
2— THIS FORM MUST BE KEPT CONFIDENTIAL —
FW-001
FOR COURT USE ONLY
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):
To keep other people from
seeing what you entered on
COURT
your form, please press the
COUNTY OF
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clear This Form button at the
:
Index No.
TELEPHONE NO.:
FAX NO. (Optional):
end of the form when finished.
E-MAIL ADDRESS (Optional):
:
Calendar No.
ATTORNEY FOR (Name):
NAME OF COURT:
:
JUDICIAL SUBPOENA
Plaintiff(s)
STREET ADDRESS:
-against-
MAILING ADDRESS:
:
CITY AND ZIP CODE:
:
BRANCH NAME:
PLAINTIFF/ PETITIONER:
:
DEFENDANT/ RESPONDENT:
APPLICATION FOR
CASE
Defendant(s)
NUMBER:
:
WAIVER OF COURT FEES AND COSTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I request a court order so that I do not have to pay court fees and costs.
1. a.
I am not able to pay any of the court fees and costs.
b.
I am able to pay only the following court fees and costs (specify):
THE PEOPLE OF THE STATE OF NEW YORK
2. My current street or mailing address is (if applicable, include city or town, apartment no., if any, and zip code):
TO
3. a. My occupation, employer, and employees address are (specify):
b. My spouse's occupation, employer, and employees address are (specify):
GREETINGS:
4.
I am receiving financial assistance under one or more of the following programs:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
a.
SSI and SSP: Supplemental Security Income and State Supplemental Payments Programs
the Honorable
at the
Court
,
b.
CalWORKs: California Work Opportunity and Responsibility to Kids Act, implementing TANF, Temporary Assistance
located at
County of
for Needy Families (formerly AFDC)
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
c.
Food Stamps: The Food Stamp Program
or adjourned date, to testify and give evidence as a witness in this action on the part of the
d.
County Relief, General Relief (G.R.), or General Assistance (G.A.)
5. If you checked box 4, you must check and complete one of the three boxes below, unless you area defendant in an unlawful
detainer action. Do not check more than one box.
a.
(Optional) My Medi-Cal number is (specify):
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
b.
(Optional) My social security number is (specify):
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
and my date of birth is (specify):
-
-
result of your failure to comply.
[Federal law does not require that you give your social security number. However, if you don't give your
social security number, you must check box c and attach documents to verify the benefits checked in item 4.]
Witness, Honorable
, one of the Justices of the
c.
I am attaching documents to verify receipt of the benefits checked in item 4, if requested by the court.
Court in
County,
day of
, 20
[See Form FW-001-INFO, Information Sheet on Waiver of Court Fees and Costs, available from the clerk's
office, for a list of acceptable documents.]
[If you checked box 4 above, skip items 6 and 7, and sign at the bottom of this side.]
My total gross monthly household income is less than the amount shown on the Information Sheet on Waiver of Court Fees
6.
(Attorney must sign above and type name below)
and Costs available from the clerk's office.
[if you checked box 6 above, skip item 7, complete items 8, 9a, 9d, 9f, and 9g on the back of this form, and sign at the bottom of
this side.]
Attorney(s) for
My income is not enough to pay for the common necessaries of life for me and the people in my family whom I support and
7.
also pay court fees and costs. [If you check this box, you must complete the back of this form.]
WARNING: You must immediately tell the court if you become able to pay court fees or costs during this action. You may
be ordered to appear in court and answer questions about your ability to pay court fees or costs.
Office and P.O. Address
I declare under penalty of perjury under the laws of the State of California that the information on both sides of this form and all
attachments are true and correct.
Date:
Telephone No.:
Facsimile No.:
(TYPE OR PRINT NAME)
(SIGNATURE)
(Financial information on reverse)
Page 1 of 2
E-Mail Address:
Form Adopted for Mandatory Use
APPLICATION FOR WAIVER OF COURT FEES AND COSTS
Government Code,
Mobile Tel. No.:
§ 68511.3
Judicial Council of California
(Fee Waiver)
FW-001 [Rev. January 1, 2007]
American LegalNet, Inc.
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