Superior Court of California, County of Sacramento Family Law Public Service Unit SACRAMENTO SUPERIOR COURT _______________ Case Number: ___________ NOTICE TO APPLICANT RE: VERIFICATION RESULTS vs. _______________ TO: ___________ 1. On __________ you filed an application for waiver of court fees and costs declaring under penalty of perjury that you are receiving financial assistance under one or more of the following programs: … … … … SSI and SSP CalWORKS (formerly AFDC) Food Stamps County Relief, General Relief or General Assistance 2. Government Code Section 68511.3(a) authorizes the courts to verify the financial status of litigants applying for a waiver of court fees and costs. On _________, this court contacted the Department of Human Assistance to confirm your benefit eligibility. This agency was unable to verify that you are currently receiving aid. PLEASE TAKE NOTICE THAT you have ten (10) days from the date this notice was mailed to submit either: (1) written documentation confirming you are currently receiving financial assistance; or, (2) pay the filing fees previously waived, to the courthouse located at 3341 Power Inn Road, Room 100, Sacramento, CA 95826. A copy of this notice must accompany the written documentation or filing fees. Said documentation or filing fees must be submitted to the court prior to any scheduled hearing date. Failure to provide the required documentation or pay filing fees will result in the voiding of document(s) previously filed by you. DATED: __________ _________________________________ Deputy Clerk CLERK’S CERTIFICATE OF MAILING I declare that I am an employee of the Sacramento Superior Court, over 18 years of age, a United States citizen, and not a party to this action. I served this Notice to Applicant Re: Verification Results by depositing a copy thereof in a sealed envelope, postage prepaid, in the United States mail at Sacramento, California on the date indicated below. Said envelope was addressed as follows: I declare under penalty of perjury that the foregoing is true and correct. DATED: ____________ FL\E-LP-630 (Rev. 1/29/2009) _________________________________ Deputy Clerk Notice to Applicant RE: Verification Results Page 1 Government Code Section 68511.3(a) American LegalNet, Inc. www.FormsWorkflow.com