ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

JV-136

TELEPHONE NO.:

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF  

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CHILD(REN)'S NAME(S):

JUVENILE DEPENDENCY—COST OF APPOINTED COUNSEL: 
REPAYMENT RECOMMENDATION/RESPONSE/ORDER

CASE NUMBER:

REIMBURSEMENT RECOMMENDATION OF FINANCIAL EVALUATION OFFICER

On (date):                                      , (name):                                                            , a person responsible for the support of the children 
named above, was ordered to report for an evaluation to determine his or her ability to reimburse the court's cost of legal services 
provided directly to him or her or to the children named above in this case.                        

The responsible person:

a.

b.

c.

The responsible person

has been reunified with the children under a court order. Repayment would harm his or her ability to support the 
child(ren). I do not, therefore, petition the court for an order of repayment. 

did not appear as ordered or respond to the order. As required by law, I recommend and petition that the court order that 
person to repay the full cost of legal services, in the amount of $ 

did appear as ordered. Based on an interview concerning his or her financial condition and an analysis of his or her 
financial declaration and supporting documentation, I find that the responsible person (check all that apply):

is unable to repay the costs of the legal services in this case.

is able to repay the cost of legal services provided directly to him or her in the amount of $              .

is able to repay the cost of legal services provided to the child(ren) named above in the amount of $                   

has agreed to repayment on the terms set forth above. I petition the court to order repayment on these terms.

disputes this assessment of his or her ability to repay the assessed costs and has requested a hearing.

A hearing is scheduled:

Date:

Time:

Dept./Room:

           at Court address above

           other (address):

The responsible person is ordered to appear at the above time and place without further notice.

1.

2.

3.

4.

5.

Date:

(NAME OF FINANCIAL EVALUATION OFFICER)

(SIGNATURE OF FINANCIAL EVALUATION OFFICER)



Form Approved for Alternative Optional Use
 Instead of Forms JV-133, JV-134, JV-135
Judicial Council of California 
JV-136 [New January 1, 2013]

JUVENILE DEPENDENCY—COST OF APPOINTED COUNSEL: 
REPAYMENT RECOMMENDATION/RESPONSE/ORDER

Page 1 of 3

Welfare and Institutions Code, §§ 903.1, 
903.45(b), 903.47
www.courts.ca.gov

CHILDREN’S NAMES:

CASE NUMBER:

JV-136

RESPONSIBLE PERSON'S RESPONSE
I (name):                                                              , am a responsible person in this case. After a financial evaluation to determine my 
ability to pay:                        

I agree to repay the court for the cost of my legal services in the amount of $                    , as recommended by the financial 
evaluation officer above. 

I also agree to repay the court for the cost of legal services provided to the child(ren) in this case in the amount of 
$                    , as recommended by the financial evaluation officer above.

I promise to pay $            on the (1st, 2nd, etc.):                day of every month, beginning on (date):                               until 
the amount is paid in full.

I waive my right to a hearing on the recommendation and understand that the court will order me to pay the 
agreed amount under the terms above.
I understand that if I default on these payment terms, the entire balance will become immediately due and 
payable.

I dispute the recommendation of the financial evaluation officer regarding my ability to pay, and I have requested a 
hearing before the court to review that recommendation.

I understand that a hearing has been scheduled on:

Date:

Time:

Dept./Room:

           at Court address above

           other (specify address):

I also understand that if I do not appear at this hearing and do not pay in full the assessed costs for legal 
services, the court may enter a judgment against me based on the financial evaluation officer's 
recommendation without further notice or order.

To be represented by a lawyer and, if I cannot afford a lawyer, to have a lawyer appointed to 
represent me.

I understand that I am entitled to the following at the hearing:

The opportunity to be heard in person;
The opportunity to present witnesses and written evidence;
The opportunity to confront and cross-examine witnesses brought against me;

Disclosure of the evidence against me;

A written statement of the findings of the court; and

• • • • • •

10.

I understand that, at any time before full payment of the amount ordered by the court, I may petition the court to change its 
judgment if a change in circumstances affects my ability to pay the judgment.

I declare under penalty of perjury under the laws of the State of California that the above information is true and correct.

Date:



( SIGNATURE OF RESPONSIBLE PERSON)

6.

7.

8.

9.

a.

b.

a.

b.

c.

JV-136 [New January 1, 2013]

JUVENILE DEPENDENCY—COST OF APPOINTED COUNSEL: 
REPAYMENT RECOMMENDATION/RESPONSE/ORDER

Page 2 of 3

CHILDREN’S NAMES:

CASE NUMBER:

JV-136

COURT ORDER

To (name):                                                      , the responsible person:

The court orders the responsible person to repay to the court the cost of legal services rendered directly to him or her in 
this case in the amount of $            

The court orders the responsible person to repay to the court the cost of legal services rendered to the children named 
above in this case in the amount of $            

The court orders the responsible person to pay the court $                 on the (1st, 2nd, etc.):               day of every month, 
beginning on (date):                          until the amount is paid in full.

The court finds that the responsible person is unable to repay the cost of legal services rendered in this case directly 
to him or her or to the children named above and is not ordered to repay any costs.

Notwithstanding any determination of his or her ability to pay, the court does not order the responsible person to repay the 
cost of legal services rendered for the following reason:

a.

b.

He or she is receiving reunification services, and repayment will pose a barrier to reunification because it will 
limit his or her ability to comply with the requirements of the reunification plan or harm his or her ability to 
support the children; or

Requiring repayment would be unjust under the circumstances of the case.

This order is based on (check all that apply):

The court's review of the financial evaluation officer's recommendation as set forth on Recommendation Regarding 
Ability to Repay Cost of Legal Services (form JV-133).

The court's review of the responsible person's agreement and waiver as set forth on Response to Recommendation 
Regarding Ability to Repay Cost of Legal Services (form JV-134).

The court's review of the evidence presented at a contested hearing held on (date):            

11.

12.

13.

14.

15.

16.

17.

18.

Date:

JUDICIAL OFFICER

JV-136 [New January 1, 2013]

JUVENILE DEPENDENCY—COST OF APPOINTED COUNSEL: 
REPAYMENT RECOMMENDATION/RESPONSE/ORDER

Page 3 of 3