Form Dgs Orim 05 - Affidavit For Waiver Of Government Claims Filing Fee And Financial Information Form

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STATE OF CALIFORNIA - DEPARTMENT OF GENERAL SERVICES
Government Claims Program Fee Waiver Request Packet
DGS ORIM 05 (Rev. 05/2016)
Government Claims Program
Office of Risk and Insurance Management
Department of General Services
PO Box 989052, MS 414
West Sacramento,CA 95798-9052
1-800-955-0045 ▪
Information and Instructions
Filing Fee for Government Claims Program
Beginning August 17, 2004, anyone wishing to file a government claim for money or damages against the state
must pay a $25 filing fee unless the person qualifies for a fee waiver. (Gov. Code, § 905.2(b).)
To request a fee waiver, you must fill out the attached
Affidavit for Waiver of Government Claims Filing Fee and Financial Information Form.
Step Instructions for filling out each step on the attached form. The form begins on page 3 of this packet.
On the attached form, provide the full name of the person requesting the fee waiver.
Provide a daytime telephone number.
If you already have a claim number and you know what it is, write it in this space.
Provide complete contact information for your employer and your spouse’s employer, if applicable.
If you are an inmate in a correctional facility, please attach a certified copy of your trust account balance,
provide your Inmate Identification Number, and skip to steps
and
and complete them.
Complete this section if you are receiving financial assistance under Supplemental Security Income (SSI),
State Supplemental Payments Programs (SSPP), CalWORKS, food stamps, county relief, general relief (GR)
or general assistance (GA).
If you answered yes in this category check all types of assistance you get, then complete step
. You are
finished.
If you checked no, continue to step
.
Find the number of people in your household and check the box only if your total monthly household income
is less than the amount shown. For instance, if there are five people in your household and the total monthly
household income is less than $2,294.79 or less check E. If there are more than 8 people in your household,
calculate the income limit by adding $331.25 for each additional person to the income level for an eight-person
household. List the number of people in your household and total household income in I.
If you checked any box in this step, complete steps
through
then skip to step
.
If you cannot pay for the common items needed for daily life, such as food, shelter, medical care and personal
safety for you and your household members, check yes in this category.
If you check yes to this question, fill in steps
through
.

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