APP-016/FW-016

Order on Court Fee Waiver (Court 
of Appeal or Supreme Court)

Clerk stamps date here when form is filed.

 1

Person who asked the court to waive court fees:

State:

Zip:

Lawyer, if person in        has one: (Name, address, phone number, e-mail, 
 1
and State Bar number):

Fill in court name and street address:

On (date):                            you filed a Request to Waive Court Fees (form 
FW-001).

Court of Appeal or Supreme Court 
Case Number:

The court reviewed your request and makes the following order:

a. 

The court grants your request and waives your court fees and costs listed below. You do not have to pay  
fees for the following: 

•  Filing notice of appeal, petition for writ, or petition for review

Other (specify):

b.

The court denies your request for the following reasons:

Your request is incomplete. You have 10 days from the date this notice was sent to:
•  Pay your fees and costs, or
•  File a new revised request that includes the items listed below (specify incomplete items):

The information you provided on the request shows that you are not eligible for the fee waiver you 
requested (specify reasons):

You have 10 days from the date this notice was sent to:
•  Pay your fees and costs, or
•  File more information that shows you are eligible.
The court finds there is substantial question regarding your eligibility (describe issue regarding 
eligibility):

You have 10 days from the date this notice was sent to:
•  Pay your fees and costs, or
•  File the following additional documents to support your request:

Name:

City:

Street address:

Phone number:

2

3 4

(1)

(2)

(3)

Warning! 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, your appeal may be dismissed.

Judicial Council of California, www.courts.ca.gov
Rev. July 1, 2010
Government Code, § 68634.5

Order on Court Fee Waiver 
(Court of Appeal or Supreme Court)

APP-016/FW-016, Page 1 of 2

Court of Appeal/
Supreme Court Case Name: 

Court of Appeal/Supreme Court 
Case Number: 

4

c. 

The court needs more information. You must go to court on the date below.

Hearing
Date

>_

Date:

Time:

Dept.:

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.

4

Date:

Signature of (check one):       Judicial Officer        Clerk, Deputy

Rev. July 1, 2010 

Order on Court Fee Waiver 
(Court of Appeal or Supreme Court)

APP-016/FW-016, Page 2 of 2