Fill and Sign the Fee Waivers Gettingstartedselfhelp California Courts Form

APP-016/FW-016 Order on Court Fee Waiver (Court of Appeal or Supreme Court) Person who asked the court to waive court fees: Name: Stre et addres s: Zip: Stat e: City: Ph on e nu mber: Law yer, if person i n has one: (Name, addre ss, phone number, e-mail, and State Bar number): On ( date): yo u f iled a Request to Waive Cour t Fees (form FW -001) . Court of Appeal or Su preme Court Case Num ber: The court reviewed your re quest an d mak es the fol lowin g ord er: The court gra nts your request and waive s your court fees and cos ts listed below. You do no t have to pay fees for the following: a. Other (specify): b. The court denies your request for the following reasons: APP-0 16/FW-016 , Page 1 of 2 Rev . July 1, 2010 Government Code, § 68 634.5 Clerk s tamps dat e here when f orm is filed. • Pay your fees and costs, or • File more information that shows you are eligible. • Fil ing not ice of appeal, peti tion f or wri t, or petiti on for revi ew 1234 (1) Your request is i ncomplete. You have 10 da ys from the da te this notice was sent to: • Pay your fees and costs, or • File a new revised reques t tha t incl udes the items listed below (spe cify i ncomp lete items): (2) Th e in formatio n yo u pro vide d on the re qu est show s that you are not eligible for the fee waiver you reque sted (spe cify re asons) : (3) The court finds there is substantia l questi on regarding your eli gibili ty (describe iss ue regarding eli gibilit y): You h ave 10 da ys from the date this notice was sent to: • Pay your fees and costs, or • File the followi ng ad ditio nal docu men ts to su pp ort yo ur requ est: You h ave 10 da ys from the date this notice was sent to: Wa rn ing! If you miss the deadline for paying your fees and costs or providing the additional items required by the court and you are the appellant, yo ur app eal may be dismiss ed. 1 Order on Court Fee Waiver (Cour t o f Ap pea l or Su preme Cour t) Fill in cou rt na me and stree t address: Judicial Council of Ca lifornia The court needs more information. You must go to court on the date below. c. Dept.: Date: Time: Hearing Date Name and address of the court if different from page 1: Bring the following proof to support your request, if it is reasonably available: Warning! If item c. is checked and you do not go to court on your hearing date, the court will deny your request to waive court fees and you will have 10 days to pay your fees. If you are the appellant and you do not pay your filing fees, your appeal may be dismissed. Date: Signature of (check one): Judicial Officer Clerk, Deputy Rev. July 1, 2010 APP-016/FW-016 , Page 2 of 2 Court of Appeal/Supreme Court Case Number: Court of Appeal/ Supreme Court Case Name: > _ Order on Court Fee Waiver (Court of Appeal or Supreme Court) 4 4