FW-001
Request to Waive Court Fees
Clerk stamps date here when form is filed.
Fill in court name and street address:
Case Number:
Judicial Council of California, www.courts.ca.gov
FW-001,
Page 1 of 2
Revised March 2, 2018, Mandatory Form
Request to Waive Court Fees
Government Code, § 68633
Fill in case number and name:
Case Name:
Street or mailing address:
Phone:
1
Your Information
Name:
CONFIDENTIAL
City: State: Zip:
Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number):
4
What court's fees or costs are you asking to be waived?
3
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,
Your financial situation improves during this case, or
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.
(person asking the court to waive the fees):
2
Your Job,
Name of employer:
if you have one (job title):
Employer's address:
a. The lawyer has agreed to advance all or a portion of your fees or costs (check one): Yes No
b. (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.
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).)
Family Size
1
2
$1,264.59
Family Income
$1,714.59
Family Size
3
4
$2,164.59
$2,614.59
Family Income
Family Size
5
6
$3,064.59
$3,514.59
Family Income
If more than 6 people
at home, add $450.00
for each extra person.
5
Why are you asking the court to waive your court fees?
I receive (check all that apply; see form FW-001-INFO for definitions):
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.)
a.
b.
Medi-Cal
Food Stamps Supp. Sec. Inc.
SSP County Relief/Gen. Assist. IHSS CalWORKS or Tribal TANF
c.
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
6
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
Cal. Rules of Court, rules 3.51, 8.26, and 8.818
CAPI
Superior Court of California, County of
Santa Clara
191 North First Street
San Jose, CA 95126
Carla Consumer
DTS
123 The Alameda, Apt. 12
San Jose, CA 95126
(408) 555-1234
18cv123456
Waitress
Debt Buyer v. Consumer
Circle M Restaurant
12 Main Street, Campbell, CA 95551
n/a
X
X
October 30, 2018
Carla Consumer
Type the
information into the
box to the right and
type your
information into
section 1.
If you are 'unemployed' or 'retired' or 'disabled' say so in section
2. Otherwise provide your work information.
Type your case number and short
title into the box above.
If you receive any of the benefits listed in section 5.a. below check
the boxes and sign below. You don't have to fill out the 2nd page
or parts 5.b. or 5.c if you receive any of these benefits.
If your GROSS monthly
earnings are lower than
the amount indicated by
the chart on the left,
check box b and
complete all of page 2.
If you earn more but you
still can't afford to pay
the filing fee, check box
c and complete all of
page 2.
This form is ONLY for folks who
can't afford to pay the court
filing fees listed on page 4.
Skip this form and the order on
pp. 21-22 if you can pay the
court fee.