Fee Waiver Application

Cal. Super. - 6th Dist.March 26, 2021

DocuSign Envelope ID: DC376A40-2E9A-401 E-92C4-53CAB4E468DF FW-001 Request to Waive Court Fees Ifyou are getting public benefits, are a low-income person, or d0 not have enough income t0 pay for your household’s basic needs and your court fees, you may use this form t0 ask the court to waive your court fees. The court may order you t0 answer questions about your finances. If the court waives the fees, you may still have t0 pay later if: ° You cannot give the court proof 0f your eligibility, - Your financial situation improves during this case, 0r - You settle your civil case for $10,000 0r more. The tfial 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 t0 waive thefees): Name: Irene Garcia Street 0r mailing address: 2394 Mather Drive City: San Jose State:Q Zip: 95116 Phone: 408-561-5 1 59 Egbtmpfl'w[yrFflgdform is filed, by Superior Court of CA, County of Santa Clara, on 3/26/2021 1:16 PM Reviewed By: M Vu E’ergggnegmggddress; Superior Court of California, County of Santa Clara Downtown Superior Court 191 North First Street San Jose, CA 951 13CD Fill in case number and name: Case Number: 21 CV381 389 ® Your Job, if you have one (job title): n/aName of employer: Case Name: Garcia V DoEmployer’s address: G) Your Lawyer, if you have one (name, firm 0r afl‘iliation, address, phone number, and State Bar number): E.]E.;SE11223|2:;I] I :EE EE.]E.333HS E. 5:2: HIM. Z 9|“: RRR NA 77H a. The lawyer has agreed to advance all 0r a portion 0fyour fees or costs (check one): Yes D No E b. (Ifyes, your lawyer must sign here) Lawyer’s signature: Ifyour lawyer z's notproviding legal-aid type services based 0n your low income, you may have t0 g0 t0 a hearing t0 explain why you are asking the court t0 waive thefees. What court’s fees or costs are you asking to be waived? E Superior Court (See Information Sheet 0n Waiver ofSuperior Court Fees and Costs (form FW-OOl-INFO).) D Supreme Court, Court 0fAppeal, 0r Appellate Division 0f Superior Court (See Information Sheet 0n Waiver oprpellate Court Fees (form APP-Ol 5/FW-01 5-INFO).) Why are you asking the court to waive your court fees? a. E Ireceive (check all that apply; seeform FW-OOI-INFOfor definitions): E Food Stamps E Supp. Sec. Inc. D SSP E Medi-Cal D County Relief/Gen. Assist. E IHSS D CaIWORKS or Tribal TANF D CAPI b. D My gross monthly household income (before deductions for taxes) is less than the amount listed below. (If you check 5b, you mustfill out 7, 8, and 9 0n page 2 0fthisf0rm.) Family Size Family Income Family Size Family Income Family Size Family Income [fmore than 6people 1 $1,301.05 3 $2,221.88 5 $3,142.71 at home, add $460.42 2 $1 ,761 .46 4 $2,682.30 6 $3,603.13 for each extra person. c. D 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 andyou mustfill outpage 2): D waive all court fees and costs D let me make payments over time © D Check here if you asked the court to waive your court fees for this case in the last six months.(Ifyour previous request is reasonably available, please attach it t0 thisform and check here:) D 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. DocuSigned by: Wan» TgfifimEuEm. Date: March 8, 2021 Request to Waive Court Fees D waive some of the court fees Irene UaICIa Print your name here Judicial Council of California, www.courts.ca.gov Revised March 15, 2019, Mandatory Form Government Code, § 68633 Cal. Rules of Court, rules 3.51, 8.26, and 8.818 FW-001, Page 1 of 29 Vu DocuSign Envelope ID: D0376A40-2E9A-401 E-9204-53CAB4E468DF Case Number: Your name: Irene Garcia Ifyou checked 5a on page 1, do not fill out below. Ifyou checked 5b, fill out questions 7, 8, and 9 only. Ifyou checked 5c, you must fill out this entire page. Ifyou need more space, attach form MC-025 or attach a sheet ofpaper and write Financial Information and your name and case number at the top. D Check here if your income changes a lot from month to month. m Your money and Pr°perty If it does, complete the form based on your average income for a_ Cash $ the paSt 12 months' b. AII financial accounts (List bank name and amount): a Your Gross Monthly Income (1) $a. List the source and amount of any income you get each month, (2) $ including: wages or other income from work before deductions, (3) $ spousal/child support, retirement, social security, disability, C 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 forjob-related (1) $ expenses, gambling or lottery winnings, etc. (2) $ $ (1) $ (3) $ $ (2) $ d Real eState Fair Market How Much You <3) $ Address Value Still Owe (4) $ (1) $ $ b. Your total monthly income: $ (2) $ $ Household Income e. Other personal property (jewelry, furniture, furs, . . . . . stocks, bonds, etc.): . a. LIst the Income of all other persons Ilvmg In your home who Falr Market HOW Much You depend in whole or in part on you for support, or on whom you Describe Value Still Owe depend in whole or in part for support. (1) $ $ Gross Monthly (2) $ $ Name Age Relationship Income (1) - $ Your Monthly Deductions and Expenses (2) - $ 3- List any payroll deductions and the monthly amount below: <3) _ $ <1) $ (4) - $ <2) $ b. Total monthly income of persons above: $ (3) $ Total monthly income and (4) I $ househo|d income (3b p/us 9b); $ 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 $ |. Installment payments (list each below): Paid to: (1) $ (2) $ . (3) $ T0 llst any other facts you want the court to know, such as W / I I hh Id b d unusual medical expenses, etc., attach form MC-025 0r m" ages eammgs W't e y Céurt or er $ attach a sheet 0f paper and write Financial Information and n" Any 9th” monthly eXpenseS (”St eaCh below)‘ 9 your name and case number at the top. (“Pam t0" $ HOW MUCh' Check here g'fyou attach anotherpage. D $(2) Important! If your financial situation or ability to pay (3) $ court fees improves, you must notify the court Within five days 0n form FW_010. Total monthly expenses (add 11a -1 1n above). $ Revised March 15,2019 Request to waive Court Fees FW-001, Page 2 of2