ATTORNEY OF PARTY WITHOUT ATTORNEY (Name and Address) Telephone Number E-MAIL ADDRESS ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF VENTURA 800 SOUTH VICTORIA AVE. VENTURA, CA 93009 3855 226 F ALAMO ST. SIMI VALLEY, CA 93063-2110 PLAINTIFF/PETITIONER DEFENDANT/RESPONDENT APPLICATION AND ORDER FOR FEE WAIVER FOR PETITION FOR DISMISSAL CASE NUMBER: CURRENT MONTHLY INCOME MONTHLY EXPENSES Client Other (spouse) Rent or house paymen t Food & Household Supplies $ $ Monthly take home pa y $ $ Utilities & Telephone $ Social Security, pension, retirement $ $ Transportation Expenses Out-of-Pocket Medical & Dental $ $ CalWORKS $ $ Clothing & Laundry Expenses $ Unemployment and/or Disability $ $ Child Care $ Other Income $ $ Total Monthly Payment ( below ) $ Total $ $ Total $ MONTHLY EXPENSES CONTINUED (i.e car payments, credit cards, medical payments, other loans, Child/spousal support payment etc.) Who do you owe? Balance Owed Monthly Payment $ $ $ $ $ $ $ $ $ $ I certify that the foregoing is a complete and accurate statement of my financial situation and that I have no other additional income or assets whatsoever. You have my express permission to verify the information furnished. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature Date ORDER The $60 cost for services rendered is imposed. The Court finds the defendant does not have the ability to pay for services rendered. Date: Judge Net difference (Income minus Expenses): $ VN188 APPLICATION AND ORDER FOR FEE WAIVER FOR PETITION FOR DISMISSAL Optional Form VN188 (Rev. 01/19) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com