Form Fw-001 - Request To Waive Court Fees (Page 3 of 6) in pdf

FW-001

Request to Waive Court Fees

CONFIDENTIAL

Clerk stamps date here when form is filed.

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,

Fill in court name and street address:

• Your financial situation improves during this case, or

Superior Court of California, County of

• 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:

Fill in case number and name:

City:

State:

Zip:

Case Number:

Phone number:

Your Job, if you have one (job title):

Case Name:

Name of employer:

Employer’s address:

Your Lawyer

if you have one (name, firm or affiliation, address, phone number, and State Bar number):

The lawyer has agreed to advance all or a portion of your fees or costs (check one):

Yes

(If yes, your lawyer must sign here) Lawyer’s signature:

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?

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).)

Why are you asking the court to waive your court fees?

I receive (check all that apply; see form FW-001-INFO for definitions):

Food Stamps

Supp. Sec. Inc.

SSP

Medi-Cal

County Relief/Gen. Assist.

IHSS

CalWORKS or Tribal TANF

CAPI

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.)

Family Size

Family Income

Family Size

Family Income

Family Size

Family Income

If more than 6 people

$1,256.26

$2,127.09

$2,997.92

at home, add $435.42

$1,691.67

$2,562.51

$3,433.34

for each extra person.

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):

waive all court fees and costs

waive some of the court fees

let me make payments over time

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:)

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.

Date:

Print your name here

Sign here

Request to Waive Court Fees

Judicial Council of California,

FW-001,

Page 1 of 2

Revised March 1, 2017, Mandatory Form

Government Code, § 68633

Cal. Rules of Court, rules 3.51, 8.26, and 8.818

Form Fw-001 - Request To Waive Court Fees Page 3

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