Fill and Sign the 982a17a Information Sheet on Waiver of Court Fees

Food S ta m p P ro gra mNotice of Action orF ood S ta m p I D C ard o r''P assp ort t o S erv ic e s'' G enera l R elie f/G ene ra l A ssis ta nce N otic e o f A ctio n o rC opy o f C heck S tu b o r C ounty V ouch er N UM BER I NF A M IL YFA M IL YIN CO M E1 $ 1.0 28.8 3 21,3 75.0 031,7 29.1 642.0 83.3 352 ,4 37.5 0 N UM BER I NF A M IL YFA M IL YIN CO M E6$ 2 ,7 91.6 673,1 45.8 383,5 00.0 0 E acha ddit io nal 354.4 6 IN FO RM ATIO N S H EET O N W AIV ERFW-001-INFOO F C O URT F E ES A ND C O STS(C ali f o rn ia R ule s o f C ourt, r u le 9 85)If you have been sued or if you wish to sue someone, and if you cannot afford to pay court fees and costs, you may not have to payth e m if :1 You are receiving financial assistance under one or more of the following programs:• S SI a nd S SP ( S upple m enta l S ecu rit y I n co m e a nd S ta te S upple m enta l P aym ents P ro gra m s)• CaIWORKs (California Work Opportunity and Responsibility to Kids Act, implementing TANF, Temporary Assistance for Needy Fam ilie s, f o rm erly A FD C, A id t o F am ilie s w it h D ependent C hil d re n P ro gra m )• T he F ood S ta m p P ro gra m• County Relief, General Relief (G. R.), or General Assistance (G.A.)If y o u a re c la im in g e lig ib ilit y f o r a w aiv e r o f c o urt f e es a nd c o sts b e ca use y o u r e ce iv e f in ancia l a ssis ta nce u nder o ne o r m ore o f these p ro gra m s, a nd y o u d id n ot p ro vid e y o ur M edi- C al n um ber o r y o ur s o cia l s e cu rit y n um ber a nd b ir th date , y o u m ust p ro duce do cu m enta tio n c o nfir m in g b enefit s f r o m a p ublic a ssis ta nce a gency o r o ne o f t h e f o llo w in g d ocu m ents , u nle ss y o u a re a d efe ndant in a n u nla w fu l d eta in er a ctio n:P R O GRAMVER IF IC ATIO NSS I/S SP M edi- C al C ard o r No tic e o f P la nned A ctio n o r SS I C om pute r-G enera te d P rin to ut o r Ba nk S ta te m ent S how in g S SI D eposit o r ''P assp ort t o S erv ic e s'' M ed i- C al C ard o rN otic e o f A ctio n o r C aIW ORKs/T A N F (fo rm erly k n ow n a s A FD C) In co m e a nd E lig ib ilit y V erif ic a tio n F orm o r Mo nth ly R eportin g F orm o r Ele ctr o nic B enefit T ra nsfe r C ard o r ''P assp ort t o S erv ic e s''- O R -2. Your total gross monthly household income is less than the following amounts:-O R-3. Your income is not enough to pay for the common necessaries of life for yourself and the people you support and also pay courtfe es a nd c o sts .T o a p ply , f ill o ut t h e A pplic atio n f o r W aiv er o f C ourt F ees a n d C osts ( F orm 9 82(a )(1 7)) a vaila b le f r o m t h e c le rk 's o ffic e. I f y o u cla im n o i n co m e, y o u m ay b e r e quir e d t o f ile a d ecla ra tio n u nd er p en alt y o f p erju ry . P ris o n a ndja il i n m ate s m ay b e r e quir e d to p ay u p t o t h e f u ll a m ount o f t h e f ilin g f e e.If y o u h ave a ny q uestio ns a nd c a nnot a ffo rd a n a tto rn ey, y o u m ay w is h t o c o nsu lt t h e le gal a id o ffic e , le gal s e rv ic e s o ffic e , o r la w ye r refe rra l s e rv ic e in y o ur c o unty ( lis te d in t h e Y ello w P ages u nder ''A tto rn eys'') .If y o u a re a skin g f o r r e vie w o f t h e d ecis io n o f a n a dm in is tr a tiv e b o dy u nder C ode o f C iv il P ro ce dure s e ctio n 1 094.5 ( a dm in is tr a tiv em an date ), y o u m ay a sk f o r a t r a nscrip t o f t h e a dm in is tr a tiv e p ro ce edin gs a t t h e e xp ense o f t h e a dm in is tr a tiv e b ody.Form A dopte d fo r M andato ry U se Ju dic ia l C ouncil o f C alif o rn ia FW -0 0 1-IN FO [R ev. J a nuary 1 , 2 007]IN FO RM ATIO N S H EET O N W AIV ER O F CO URT F E ES A ND C O STS (in F orm a P au peris )Government Code, § 68511.3 Cal. R ule s o f C ourt, r u le 9 86ele ctr o nic f o rm  2 004 WWW.LawCA.com La w P ublis h ers