Clerk stamps date here when form is filed.Fill in court name and street address: Superior Court of California, County of Fill in case number and name:Case Number: Case Name: CONFIDENTIAL FW-001Request to Waive Court Fees If you are getting public benefits, are a low-income person, or do not have enough income to pay for your household222s 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:225 You cannot give the court proof of your eligibility,225 Your financial situation improves during this case, or225 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: State: Zip: City: Phone: Your Job, if you have one (job title): Name of employer: Employer222s address:Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number): No Yes (If yes, your lawyer must sign here) Lawyer222s signature:The lawyer has agreed to advance all or a portion of your fees or costs (check one):Why are you asking the court to waive your court fees? b.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 court222s fees or costs are you asking to be waived?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.a. b. 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).) 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.) 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:)a. I receive (check all that apply; see form FW-001-INFO for definitions): Medi-Cal Food Stamps SSP Supp. Sec. Inc. County Relief/Gen. Assist. IHSS CalWORKS or Tribal TANF CAPIc. I do not have enough income to pay for my household222s basic needs and the court fees. I ask the court to: (check one and you must fill out page 2): let me make payments over time waive all court fees and costs Family Size Family Income Family Size Family Income Family Size Family Income 1 $1,301.05 3 $2,221.88 5 $3,142.71 2 $1,761.46 4 $2,682.30 6 $3,603.13 If more than 6 people at home, add $460.42 for each extra person. Judicial Council of California, www.courts.ca.gov Revised March 15, 2019, Mandatory Form Government Code, 247 68633 Cal. Rules of Court, rules 3.51, 8.26, and 8.818Request to Waive Court FeesFW-001, Page 1 of 2 Sign here Print your name here Date: 1 2 3 4 5 6 waive some of the court fees American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Your name: Check here if your income changes a lot from month to month. (1) $ (2) $ (3) $ (4) $ $ $ $ $ $ $ $ $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 PropertyCashAll financial accounts (List bank name and amount): (1) $Your Gross Monthly Income (2) $List any payroll deductions and the monthly amount below: (3) $ (1) $ $ (2) $ $ (3) $ $ (1) $ $ (2) $ $ (1) $ $ (2) $ $ (1) $ (2) $ (3) $ (4) $ $ $ $ $ $ $ $ $ $ $ (1) $ (2) $ (3) $ $ (1) $ (2) $ (3) $ $ To list any other facts you want the court to know, such as unusual medical expenses, etc., attach form MC-025 or attach a sheet of paper and write Financial Information and your name and case number at the top. Check here if you attach another page. Wages/earnings withheld by court orderAny other monthly expenses (list each below).Paid to:How Much?Important! If your financial situation or ability to pay court fees improves, you must notify the court within five days on form FW-010.Total monthly expenses (add 11a 22611n above):If it does, complete the form based on your average income for the past 12 months.a.h.Fair Market ValueHow Much You Still OweCars, boats, and other vehiclesc.Fair Market ValueHow Much You Still OweMake / YearList the source and amount of any income you get each month, including: wages or other income from work before deductions, spousal/child support, retirement, social security, disability, unemployment, military basic allowance for quarters (BAQ), veterans payments, dividends, interest, trust income, annuities, net business or rental income, reimbursement for job-related expenses, gambling or lottery winnings, etc.a.Real estated.Fair Market ValueHow Much You Still OweAddressa.Ageb.Total monthly income of persons above:i.School, child caree.Other personal property (jewelry, furniture, furs, stocks, bonds, etc.):DescribeYour total monthly income:b.Household IncomeYour Monthly Deductions and ExpensesList the income of all other persons living in your home who depend in whole or in part on you for support, or on whom you depend in whole or in part for support.Gross Monthly Incomeb.Rent or house payment & maintenance RelationshipNamec.(1)d.(2)e.Clothing(3)f.Laundry and cleaning (4)g.Child, spousal support (another marriage)j.Total monthly income and household income (8b plus 9b):Transportation, gas, auto repair and insurance k.l.Installment payments (list each below):Paid to:b.m.n.Food and household suppliesUtilities and telephoneMedical and dental expensesInsurance (life, health, accident, etc.) Revised March 15, 2019Request to Waive Court FeesFW-001, Page 2 of 2 7 8 9 10 11a. 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