Assistant Nurse
Resume:
If you are getting public benefits, are a low-income person, or do not have
enough income to pay for household’s basic needs and your court fees, you may use this form to ask the court to waive all or part of 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. Your Information (person asking the court to waive the fees): Name:
Fill in case number and name:
Case Number:
Street or mailing address:
City: State: Zip:
Phone number:
Your Job, if you have one (job title):
Employer’s address:
The lawyer has agreed to advance all or a portion of your fees or costs (check one): Yes No
(If yes, your lawyer must sign here) Lawyer’s signature: Why are you asking the court to waive your court fees? County Relief/General
Assistance IHSS (In-Home Supportive Services) CalWORKS or Tribal TANF (Tribal Temporary Assistance for Needy Families) CAPI (Cash Assistance Program for Aged, Blind and Disabled) 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 Income
If more than 6 people
at home, add $418.75
for each extra person.
1 $1,196.88 $2,034.38 5 $2,871.88
2 $1,615.63 $2453.13 6 $3,290.63
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): waive all court fees waive some of the court fees let me make payments over time
(Explain): (If you check 5c, you must fill out page 2.) Request to Waive Court Fees FW-001, Page 1 of 2
Family Size Family Size Family Income
3
4
Judicial Council of California, www.courts.ca.gov
Revised February 26, 2013, Mandatory Form
Government Code, § 68633
Cal. Rules of Court, rules 3.51, 8.26, and 8.818
1
2
5
c.
Fill in court name and street address:
FW-001 Request to Waive Court Fees CONFIDENTIAL
Clerk stamps date here when form is filed.
Case Name:
Name of employer:
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. 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? 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).)
3
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: ) 6
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
a.
b.
a. I receive (check all that apply): Medi-Cal Food Stamps SSI SSP Request to Waive Court Fees FW-001, Page 2 of 2
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 Property
Cash $
All financial accounts (List bank name and amount):
(1) $
Your Monthly Income
(2) $
Gross monthly income (before deductions):
List each payroll deduction and amount below:
$
(3) $
(4) $
(1) $
(2) $
c. Cars, boats, and other vehicles
(3) $
Fair Market
Value
How Much You
Still Owe
(4) $
Make / Year
Total deductions (add 8a (1)-(4) above): (1) $ $
(2)
b.
$ $
(3) $
Total monthly take-home pay (8a minus 8b):
List the source and amount of any other income you get each $ month, including: 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.
d.
d. Real estate Fair Market
Value
How Much You
Address Still Owe
(1) $ $
(2) $ $
(3) $ $
(1) $
e. Other personal property (jewelry, furniture, furs, stocks, bonds, etc.):
(2) $
(3) $
(4) $ Describe
(1) $ $
e. Your total monthly income is (8c plus 8d): $
(2) $ $
(3) $ $
Household Income
List all other persons living in your home and their income; Your Monthly Expenses include only your spouse and all individuals who depend in whole or in part on you for support, or on whom you depend in whole or in part for support.
(Do not include payroll deductions you already listed in 8b.) Gross Monthly
Income
a. Rent or house payment & maintenance $
Name Relationship
b. $
(1) $
c. $
(2) $
d. Clothing $
(3) $
e. Laundry and cleaning $
(4) $
f. $
$
b. Total monthly income of persons above:
h. School, child care $
$ i. Child, spousal support (another marriage)
Total monthly income and
household income (8e plus 9b):
j. Transportation, gas, auto repair and insurance
$
k. Installment payments (list each below):
Paid to:
(1) $
To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, 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.
(2) $
(3)
Wages/earnings withheld by court order
Any other monthly expenses (list each below).
Paid to: How Much?
(1) $
Important! If your financial situation or ability to pay court fees improves, you must notify the court within five days on form FW-010.
(2) $
(3) $
Total monthly expenses (add 11a –11m above): $
Check here if your income changes a lot from month to month. Fill out below based on your average income for the past 12 months.
a.
g.
$
$
c.
Fair Market
Value
How Much You
Still Owe
$
$
Case Number:
Your name:
7
8
9
10
11
$
a.
$
a.
Age
b.
l.
m.
Food and household supplies
Utilities and telephone
Medical and dental expenses
Insurance (life, health, accident, etc.)
$
Rev. February 26, 2013
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