Form Fw-001 - Request To Waive Court Fees Page 4
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1
2
3
4
5
6Case Number:
Your name:
If you checked 5a on page 1, do not fill out below. If you checked 5b, fill out questions 7, 8, and 9 only.
If you checked 5c, you must fill out this entire page. If you need more space, attach form MC-025 or attach a
sheet of paper and write Financial Information and your name and case number at the top.
Your Money and Property
10
Check here if your income changes a lot from month to month.
7
If it does, complete the form based on your average income for
a.
Cash
$
the past 12 months.
b.
All financial accounts (List bank name and amount):
$
(1)
Your Gross Monthly Income
8
$
(2)
a.
List the source and amount of any income you get each month,
including: wages or other income from work before deductions,
(3)
$
spousal/child support, retirement, social security, disability,
c.
Cars, boats, and other vehicles
unemployment, military basic allowance for quarters (BAQ),
Fair Market
How Much You
Make / Year
veterans payments, dividends, interest, trust income, annuities,
Value
Still Owe
net business or rental income, reimbursement for job-related
(1)
$
$
expenses, gambling or lottery winnings, etc.
(2)
$
$
(1)
$
(3)
$
$
$
(2)
d.
Real estate
Fair Market
How Much You
(3)
$
Address
Value
Still Owe
(4)
$
(1)
$
$
$
$
(2)
b.
Your total monthly income:
$
e. Other personal property (jewelry, furniture, furs,
Household Income
9
stocks, bonds, etc.):
Fair Market
How Much You
a.
List the income of all other persons living in your home who
Describe
Value
Still Owe
depend in whole or in part on you for support, or on whom you
(1)
$
$
depend in whole or in part for support.
Gross Monthly
(2)
$
$
Name
Age
Relationship
Income
$
(1)
Your Monthly Deductions and Expenses
11
(2)
$
a.
List any payroll deductions and the monthly amount below:
(3)
$
(1)
$
$
(4)
(2)
$
b. Total monthly income of persons above:
$
(3)
$
(4)
$
Total monthly income and
b. Rent or house payment & maintenance
$
household income (8b plus 9b):
$
c.
Food and household supplies
$
d.
Utilities and telephone
$
e. Clothing
$
f. Laundry and cleaning
$
g.
Medical and dental expenses
$
h.
Insurance (life, health, accident, etc.)
$
i.
School, child care
$
j.
Child, spousal support (another marriage)
$
k.
Transportation, gas, auto repair and insurance
$
l.
Installment payments (list each below):
Paid to:
$
(1)
$
(2)
$
(3)
To list any other facts you want the court to know, such as
m.
Wages/earnings withheld by court order
$
unusual medical expenses, etc., attach form MC-025 or
n.
Any other monthly expenses (list each below).
$
attach a sheet of paper and write Financial Information and
Paid to:
How Much?
your name and case number at the top.
$
(1)
Check here if you attach another page.
$
(2)
$
(3)
Important! If your financial situation or ability to pay
court fees improves, you must notify the court within five
Total monthly expenses (add 11a –11n above):
$
days on form FW-010.
Request to Waive Court Fees
FW-001,
Revised March 1, 2017
Page 2 of 2
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