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Question	Answer
Form Name	Fw 001 Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	123
Avg. time to fill out	25 min 10 sec
Other names	FW-001 Request to Waive Court Fees - lassd.org

12

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	FW-001	Request to Waive Court Fees		CONFIDENTIAL


				Clerk stamps date here when form is filed.
	If you are getting public benefits, are a low-income person, or do not have			Clerk stamps date here when form is filed.

	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,
	•You cannot give the court proof of your eligibility,			Fill in court name and street address:
	•Your financial situation improves during this case, or
	•Your financial situation improves during this case, or			Superior Court of California, County of
				Superior Court of California, County of

•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.

1 Your Information (person asking the court to waive the fees): Name:


	Street or mailing address:										Fill in case number and name:
	City:				State:		Zip:				Fill in case number and name:

											Case Number:
	Phone:										Case Number:
	Phone:

2Your Job, if you have one (job title):


Name of employer:					Case Name:
Name of employer:
Employer’s address:

3Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number):

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.

4What court’s fees or costs are you asking to be waived?

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).)

5Why are you asking the court to waive your court fees?


a.	I receive (check all that apply; see form FW-001-INFO for definitions):					Food Stamps Supp. Sec. Inc.
	SSP	Medi-Cal	County Relief/Gen. Assist.	IHSS	CalWORKS or Tribal TANF		CAPI

b. 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.)

Family Size	Family Income	Family Size	Family Income	Family Size	Family Income	If more than 6 people
1	$1,341.67	3	$2,287.50	5	$3,233.34	at home, add $472.92
2	$1,814.59	4	$2,760.42	6	$3,706.25	for each extra person.

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

Judicial Council of California, www.courts.ca.gov Revised March 15, 2021, Mandatory Form Government Code, § 68633

Cal. Rules of Court, rules 3.51, 8.26, and 8.818

Request to Waive Court Fees

FW-001, Page 1 of 2

Your name:

Case Number:

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.

7	Check here if your income changes a lot from month to month.
	If it does, complete the form based on your average income for

the past 12 months.

8Your Gross Monthly Income

a.List 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.

(1)		$
(2)		$
(3)		$
(4)		$
b. Your total monthly income:		$

9Household Income

a.List 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
Name			Age Relationship Income
(1)						$

(2)						$

(3)						$

(4)						$

b. Total monthly income of persons above: $

Total monthly income and
household income (8b plus 9b):	$

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.

Important! If your financial situation or ability to pay court fees improves, you must notify the court within five days on form FW-010.

10Your Money and Property

a. Cash

$

b.All financial accounts (List bank name and amount):

(1)					$

(2)					$

(3)					$

c. Cars, boats, and other vehicles
	Make / Year		Fair Market			How Much You
	Make / Year		Value			Still Owe
			Value			Still Owe
(1)		$			$

(2)		$			$

(3)		$			$

d. Real estate			Fair Market			How Much You
	Address		Value			Still Owe
(1)		$			$

(2)		$			$

e. Other personal property (jewelry, furniture, furs,
stocks, bonds, etc.):			Fair Market			How Much You
			Fair Market			How Much You
	Describe		Value			Still Owe
(1)		$			$

(2)		$			$

11Your Monthly Deductions and Expenses

a. List any payroll deductions and the monthly amount below:

(1)		$
(2)		$
(3)		$
(4)		$

b.	Rent or house payment & maintenance			$
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)			$

m. Wages/earnings withheld by court order				$

n.Any other monthly expenses (list each below).

Paid to:			How Much?
(1)		$

(2)		$

(3)		$

Total monthly expenses (add 11a –11n above): $

Revised March 15, 2021	Request to Waive Court Fees	FW-001, Page 2 of 2

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portion of blanks in Fw 001 Form

Provide the demanded information in the County, Relief, Gen, Assist MediCal, IHS, S Cal, WORKS, or, Tribal, TAN, F Food, Stamps Supp, Sec, In, cC, API Family, Size Family, Income Family, Size Family, Income Family, Size Family, Income and waive, some, of, the, court, fees box.

part 2 to entering details in Fw 001 Form

You will need to insert some details in the area Print, your, name, here www, courts, ca, gov Request, to, Waive, Court, Fees FW, Page, of and Sign, here

step 3 to entering details in Fw 001 Form

The field Your, name Case, Number Your, Money, and, Property a, Cash Your, Gross, Monthly, Income bY, our, total, monthly, income Household, Income Name, Age, Relationship Gross, Monthly, Income c, Cars, boats, and, other, vehicles Make, Year Fair, Market, Value d, Real, estate and Address will be where you can put both sides, ' rights and obligations.

Completing Fw 001 Form part 4

Check the areas Name, Age, Relationship Gross, Monthly, Income b, Total, monthly, income, of, persons, above Total, monthly, income, and household, income, b, plus, b Check, here, if, you, attach, another, page Your, Monthly, Deductions, and, Expenses Insurance, life, health, accident, etc Paid, to Paid, to and How, Much and then fill them in.

stage 5 to filling out Fw 001 Form

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