Form Dgs Orim 05 - Affidavit For Waiver Of Government Claims Filing Fee And Financial Information Form Page 3

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AFFIDAVIT FOR WAIVER OF GOVERNMENT CLAIMS
State of California
FILING FEE AND FINANCIAL INFORMATION FORM
Government Claims Program
Office of Risk and Insurance Management
Department of General Services
PO Box 989052, MS 414
For Office Use Only
West Sacramento,CA 95798-9052
Claim No.:
1-800-955-0045 ▪
I request a fee waiver so that I do not have to pay the $25 fee to file a government claim with
the Government Claims Program. I cannot pay any part of the fee.
Claimant Information
Tel:
Last name
First Name
MI
Claim Number (if known):
Employment Information
My occupation:
My employer:
Employer’s Mailing Address
City
State
Zip
My spouse’s or partner’s employer:
Employer’s Mailing Address
City
State
Zip
If you are an inmate in a correctional facility, please attach a certified copy of your trust account balance,
enter your inmate identification number below and skip to step
.
Inmate Identification Number:
Financial Information
I am receiving financial assistance from one or more of the following programs.
Yes
No
If no, proceed to step
If yes, check all that apply, then skip to step
.
SSI and SSP: Supplemental Security Income and State Supplemental Payments Programs
CalWORKS: California Work Opportunity and Responsibility to Kids Act
Food Stamps
County Relief, General Relief (GR), or General Assistance (GA)
Number in my household and my gross monthly household income, if it is the following amount or less:
Number
Monthly family income
Number
Monthly family income
1
$969.79
6
$2,626.04
A
F
2
$1,301.04
7
$2,957.29
B
G
3
$1,632.29
8
$3,288.54
C
H
4
$1,963.54
There are more than 8 people in my family
D
I
5
$2,294.79
Add $331.25 for each additional person.
E
Number:
Total Income:
If you checked a box in step
A through I, complete steps
through
. Then skip to step
.
My income is not enough to pay for the common necessities of life for me
Yes
No
and the people in my family, and also pay the filing fee.
If yes, fill in steps
through
.

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