Reduced Mediation Fee Application
Use this form to request a reduction of mediation fees based on your household size, income, and financial hardship.
Applicant Information
Please provide your basic information so we can locate your case.
Applicant Full Name
*
First Name
Last Name
Case Number
*
Household Size
*
Primary Phone Number
*
Please enter a valid phone number.
Email Address
example@example.com
Income Verification
Select your household size and the income range that best describes your total gross household income.
Household Size for Income Guidelines
*
Please Select
1 person
2 people
3 people
4 people
5 people
6 people
7 people
8 or more people
Estimated Total Gross Household Income (annual)
*
Please Select
$0 – $15,000
$15,001 – $25,000
$25,001 – $35,000
$35,001 – $45,000
$45,001 – $60,000
Over $60,000
Prefer not to say
Income Eligibility Acknowledgment
*
I certify that the information I have provided about my household size and income is true and correct to the best of my knowledge.
I understand that providing false information may result in denial or revocation of reduced fees.
Required Documentation
Indicate which documents you are providing to verify your income and upload copies if available.
Types of Documentation Provided
*
Most recent federal tax return
Recent pay stubs (last 30–60 days)
Public assistance or benefits award letter
I am currently unable to provide documentation
Other proof of income
Upload Income Verification Documents
Upload a File
Drag and drop files here
Choose a file
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Statement of Hardship (Optional)
You may provide additional information about your financial situation. This section is optional.
Statement of Hardship
Verified Statement & Signature
Please read the statement below and sign to complete your request.
Verified Statement
Applicant Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Internal Use Only – CAHASHE Review
This section is for CAHASHE staff use only.
CAHASHE Decision
Approved – Reduced fee granted
Approved – Full fee waived
Denied – Does not meet criteria
Pending – Additional information requested
Approved Fee Level / Notes
Reviewer Name
Review Date
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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