Preview
Request to Waive Court Fees
Clerk stamps date here when form is filed.
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, Fill in court name and street address:
+ Your financial situation improves during this case, or Superior Court of California, County of
+ You settle your civil case for $10,000 or more. The trial court that waives Kern
your fees will have a lien on any such settlement in the amount of the Kern County Superior Court
waived fees and costs. The court may also charge you any collection costs. 1215 Truxtun Ave
@) Your Information (person asking the court to waive the fees): Bakersfield CA 93301
Name: Gabriel Nunez Rivera
Street or mailing address: 105 Eastern Ave. Fill in case number and name.
City: Taft State: CA Zip: 93268
Case Number:
Phone: (661) 770-9327
@ Your Job, if you have one (job title): Unemployed
Name of employer: Case Name:
Employer’s address: CA
® Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number):
Rebeca Gonzalez, Rebeca Gonzalez Attorney at Law APC 329149
5330 Office Centre Ct., Suite 32, Bakersfield, CA 93309
a. The lawyer has agreed to advance all .. a portion of your fees or costs (check one): Yes No
b. (Ifyes, 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.
What court's fees or costs are you asking to be waived?
{M] Superior Court (See Information Sheet on Waiver of Superior Court Fees and Costs (form FW-001-INFO).)
C 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).)
Why are you asking the court to waive your court fees?
a. MY I receive (check all that apply; see form FW-001-INFO for definitions):
(1 Food Stamps] Supp. Sec. Inc. [] SSP Y] Medi-Cal [] County Relief/Gen. Assist. [] THSS
( CalWORKS or Tribal TANF 1 CAPI O wic ( Unemployment
b. [1 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 | J/ more than
6 people
1 $2,510.00 | 3 $4,303.34 5 $6,096.67 at home, add $896.67
2 $3,406.67 | 4 $5,200.00 6 $6,993.34 for each extra person
c. ¥] Ido 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)
M waive all court fees and costs O waive some of the court fees CO let me make payments over time
@®a Check here if you asked the court to waive your court fees for this case in the last six months.
(Uf 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.
4/23/2024
>Sign here _GaP
Date:
{Gabriel Nunez Rivera
Print your name here
Judicial Council of California, wavw.courts.ca. gov Request to Waive Court Fees FW-001, Page 1 of 2
Rev. April 1, 2024, Mandatory Form
Government Code, § 68633
Cal, Rules of Court, ries 3.51, 8.26, and 8.818 >
Case Number:
Your name: Gabriel Nunez Rivera
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 numberat the top.
® (FJ 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.
(10) ur Money and Property
Cash $
b. All financial accounts (List bank name and amount):
Your Gross Monthly Income a &
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, Cars, boats, and other vehicles
unemployment, military basic allowance for quarters (BAQ), Fair Market How Much You
veterans payments, dividends, interest, trust income, annuities, Make / Year Value ‘Still Owe
net business or rental income, reimbursement for job-related qa) S$
expenses, gambling or lottery winnings, etc.
@ S$
a @ S$.
(2) Real estate Fair Market How Much You
(3) Address Value ‘Still Owe
4) a §.
b. Your total monthly income: (2) $
lousehold Income e. Other personal property (jewelry, furniture,
stocks, bonds, etc): Fair Market How Much You
. List the income of ail other persons living in your home who
depend in whole or in part on you for support, or on whom you: Describe Value a Owe
depend in whole or in part for support, a
Gross Monthly @ $. S.
Name Age Relationship Income
@»
(1) — ‘our Monthly Deductions and Expenses
(2) a 5. List any payroll deductions and the monthly amount below:
@), —. $
Q) $.
(4) — $
(2) &
b, Total monthly income of persons above: S. @) &
Total monthly income and @) $
household income (8b pits 9b): $. Rent or house payment & maintenance
Food and household supplies
Utilities and telephone
Clothing
Laundry and cleaning
Medical and dental expenses
Insurance (life, health, accident, etc.)
School, child care
Child, spousal support (another marriage)
k. Transportation, gas, auto repair and insurance
L Installment payments (list each below):
Paid to:
(ty
2)
@)
To list any other facts you want the court to know, such as
unusual medical expenses, etc., attach form MC-025 or Wagesiearnings withheld by court order
attach a sheet of paper and write Financial Information and Any other monthly expenses (list each below).
Paid to: How Much?
your name and case number at the top.
Check here if you attach another page. (]
a) %.
2) $.
Important! If your financial situation or ability to pay 3) $,
court fees improves, you must notify the court within five
Total monthly expenses (add 74a—11n above): $
days on form FW-010.
Rev. April 1, 2024 Request to Waive Court Fees FW-001, Page 2 of 2