This form contains 62 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Alternate Court Address
Alternate Court Address Text
Enter the name and full address of the court if it is different from the court already specified on the form.
Basis of Court Review
Request to Waive Court Fees Checkbox
Check this box if your request is to waive court fees.
Request to Waive Additional Court Fees Checkbox
Check this box if your request is to waive additional court fees.
Case Number
Case Number Text
Provide the case number for this form.
Case Number Text
Enter the case number.
Clerk Name
Clerk Name Text
Enter the full name of the clerk.
Clerk's Certificate of Service
1. Handed Copy at Court Radiobutton
Check this box if you, as the certifying clerk, personally handed a copy of this Order to the party and attorney at the court.
2. Mailed First Class Radiobutton
Check this box if you, as the certifying clerk, mailed this Order first-class, postage paid, to the party and attorney at the listed addresses.
Clerk's Certificate Date of Service Date
Provide the date on which the Clerk's Certificate of Service is issued.
3. Certificate of Mailing Attached Checkbox
Check this box if a separate certificate of mailing for this service is attached.
Clerk's Certificate City of Mailing Text
Provide the city from which the Clerk's Certificate of Service was mailed.
Court and Case Information
Court Name and Address Text
Provide the full name and street address of the Superior Court of California, including the county.
Case Number Text
Enter the official case number assigned to this legal matter.
Case Name Text
Provide the full legal name of the case.
Court Denial Checkbox
The court denies your fee waiver request because CheckBox
Court's Grant of Request
Fee Waiver Checkbox
Check this box if the court grants the initial fee waiver and waives the listed court fees and costs.
Additional Fee Waiver Checkbox
Check this box if the court grants an additional fee waiver and waives the checked additional superior court fees and costs.
The court grants your request, as follows CheckBox
Fee Waiver Request Details
Request Filing Date Date
Enter the date when the request to waive court fees was filed.
Previous Fee Waiver Order Checkbox
Check this box if the court made a previous fee waiver order in this case.
Previous Order Date Date
Enter the date when the court made a previous fee waiver order in this case.
General
Print this form Button
Save this form Button
Clear this form Button
For your protection and privacy, please press the Clear This Form button after you have printed the form Button
Hearing Information
Hearing Date Date
Enter the date of the hearing.
Hearing Time Time
Enter the time of the hearing.
Hearing Room Text
Enter the room number or name where the hearing will take place.
Hearing Department Text
Enter the department associated with the hearing.
Incomplete Request Details
Incomplete Items List 1 Text
Enter the list of incomplete items that need to be included in the revised request.
Incomplete Items Below Radiobutton
Check this box if the incomplete items that need to be revised are listed below the current instruction.
Incomplete Items On Attachment 4b(1) Radiobutton
Check this box if the incomplete items that need to be revised are listed on Attachment 4b(1).
Your request is incomplete. You have 10 days after the clerk gives notice of this Order (see date of service on next page) to CheckBox
Ineligibility Details
Ineligibility Reason 2: Not Eligible Based on Information Provided Checkbox
Check this box if the court denies the fee waiver because the information provided in the request shows the applicant is not eligible.
Ineligibility Reason 2 Details: Stated Below Radiobutton
Check this box if the specific reasons for ineligibility, as described under section (2), are listed directly below on this form.
Ineligibility Reason 2 Details: Stated On Attachment 4b(2) Radiobutton
Check this box if the specific reasons for ineligibility, as described under section (2), are provided on Attachment 4b(2).
Specific Ineligibility Reasons Text
Enter the specific reasons why the fee waiver request was denied based on the information provided.
Lawyer Information
Lawyer Information Text
Enter the lawyer's name, firm name, address, phone number, e-mail, and State Bar number.
List of Required Proof
Bring the items of proof to support your request, if reasonably available, that are listed CheckBox
c.(2) Below Radiobutton
Check this box if the required items of proof are listed in the section immediately below this checkbox.
c.(2) On Attachment 4c(2) Radiobutton
Check this box if the required items of proof are listed on Attachment 4c(2).
List of Required Proof Text
Enter the list of items of proof required to support the request, if reasonably available.
Person Who Asked to Waive Court Fees
Person 1 Name Text
Enter the full name of the person who asked the court to waive court fees.
Person 1 Street or Mailing Address Text
Enter the street or mailing address of the person who asked the court to waive court fees.
Person 1 City Text
Enter the city of the person who asked the court to waive court fees.
Person 1 State Text
Enter the state of the person who asked the court to waive court fees.
Person 1 Zip Code Text
Enter the zip code of the person who asked the court to waive court fees.
Questions for Hearing
Eligibility Questions for Hearing Text
Provide the specific questions regarding your eligibility for the fee waiver that will be discussed at the hearing.
The court needs more information to decide whether to grant your request. You must go to court on the date on page 3. The hearing will be about the questions regarding your eligibility that are stated CheckBox
First Question for Hearing Below Radiobutton
Check this box if the court needs more information, and the questions regarding your eligibility for the hearing are stated below this point on the form.
First Question for Hearing On Attachment 4c(1) Radiobutton
Check this box if the court needs more information, and the questions regarding your eligibility for the hearing are stated on Attachment 4c(1).
Signature
Signature Date Date
Enter the date the form is signed.
Judicial Officer Radiobutton
Check this box if the signature or authority is from a Judicial Officer.
Clerk, Deputy Radiobutton
Check this box if the signature or authority is from a Clerk or Deputy.
Waived Additional Fees
Jury fees and expenses CheckBox
Fees for a peace officer to testify in court Checkbox
Check this box if you want the court to waive fees for a peace officer to testify in court.
Court-appointed interpreter fees for a witness Checkbox
Check this box if you want the court to waive fees for a court-appointed interpreter for a witness.
Fees for court-appointed experts Checkbox
Check this box if you want the court to waive fees for court-appointed experts.
Waived Additional Fees Other Specify Text
Enter any other additional fees that are being waived by the court.
Other Waived Additional Fees Checkbox
Check this box if you want the court to waive additional superior court fees and costs not listed above, and you must specify them in the provided space.
Your Name
Your Name Text
Enter your full name.
Your Name Text
Please enter your full name.