FW + HIPPA + Verification

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PLEASE SCREENSHOT THIS SCREEN FOR YOUR RECORDS!
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Clerk stamps date here when form is filed.

If you are getting public benefits, are a low-income person, or do not have enough income to pay for your household’s basic needs and your court fees, you may use this form to ask the court to waive your court fees. The court may order you to answer questions about your finances. If the court waives the fees, you may still have to pay later if:

You cannot give the court proof of your eligibility,

Your financial situation improves during this case, or

You settle your civil case for $10,000 or more. The trial court that waives your fees will have a lien on any such settlement in the amount of the waived fees and costs. The court may also charge you any collection costs.
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Superior Court of California, County of* This field is required.
i.e. Los Angeles
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Case Number* This field is required.24STUDXXXXX
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Case Name:* This field is required.Plaintiff vs. Defendant (Your Name)
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Full Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number* This field is required.
Please enter a valid phone number.
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Email
example@example.com
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Job Title* This field is required.
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Employer Name* This field is required.
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Employer Address* This field is required.
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Select Your Attorney* This field is required.
Please Select
Please Select
Kingsley Opia-Enwemuche, Esq.
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Attorneys Address* This field is required.
Please Select
Please Select
21818 Craggyview St., Ste. 201, Chatsworth, CA 91311
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Attorney's Phone Number* This field is required.
Please Select
Please Select
Office: 855-776-8550
Direct: 747-305-6545
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Attorneys State Bar Number* This field is required.
Please Select
Please Select
#339407
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a. The lawyer has agreed to advance all or a portion of your fees or costs (check one)* This field is required.
Yes
No
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What court fees are you asking to be waived?* This field is required.
Superior Court
Supreme Court, Court of Appeal, or Appellate Division of Superior Court
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a. Why are you asking the court to waive your court fees?* This field is required.
I received (Check all that apply):
Food Stamps
Supp. Sec. Inc.
SSP
Medi-Cal
County Relief/Gen. Assist.
IHSS
CalWORKS or Tribal TANF
CAPI
Other
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Is your Gross Monthly Income Less than whats presented?
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b. If yes, check the box below.* This field is required.If his item is selected you MUST complete questions 7, 8, and 9
My gross monthly household income (before deductions for taxes) is less than the amount listed below.
Other
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Check all that apply to you* This field is required.
I do not have enough income to payor my household's basic needs and the court fees. I ask the court to:
Waive all court fees and cost
Waive some of the court fees
Let me make payments over time.
Check here if you asked the court to waive your court fees for this case in the last 6 months.
Other
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I declare under penalty of perjury under the laws of the State of California that the information I have provided on this form and all attachments are true and correct.* This field is required.Select Today's Date
Date
Year
Month
Day
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Type your full name here* This field is required.
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Signature* This field is required.
Powered by Jotform SignClear
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Your Name* This field is required.
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Case Number* This field is required.24SUDXXXXX
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If you checked 5a on page 1, do not fill out below. If you checked 5b, fill out questions 7, 8, and 9 only. If you checked 5c, you must fill out this entire page. If you need more space, attach form MC-025 or attach a sheet of paper and write Financial Information and your name and case number at the top.
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* This field is required.
Check here if your income changes a lot from month to month. If it does, complete the form based on your average income for the past 12 months.
NO
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Your Gross Monthly Incomea. List the source and amount of any income you get each month, including: wages or other income from work before deductions, spousal/child support, retirement, social security, disability, unemployment, military basic allowance for quarters (BAQ), veterans payments, dividends, interest, trust income, annuities, net business or rental income, reimbursement for job-related expenses, gambling or lottery winnings, etc.
Source
Amount
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Total
Source
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Amount
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Household Income
Full Name
Age
Relationship
Gross Monthly Amount
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Row 3, Column 3
Total Monthly Income of Persons Above
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Row 4, Column 3
1
2
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Total Monthly Income of Persons Above
Full Name
Row 0, Column 0
Age
Row 0, Column 1
Relationship
Row 0, Column 2
Gross Monthly Amount
Row 0, Column 3
Full Name
Row 1, Column 0
Age
Row 1, Column 1
Relationship
Row 1, Column 2
Gross Monthly Amount
Row 1, Column 3
Full Name
Row 2, Column 0
Age
Row 2, Column 1
Relationship
Row 2, Column 2
Gross Monthly Amount
Row 2, Column 3
Full Name
Row 3, Column 0
Age
Row 3, Column 1
Relationship
Row 3, Column 2
Gross Monthly Amount
Row 3, Column 3
Full Name
Row 4, Column 0
Age
Row 4, Column 1
Relationship
Row 4, Column 2
Gross Monthly Amount
Row 4, Column 3
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Total monthly income and household income $ * .
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* This field is required.
Amount
Cash On-Hand
Row 0, Column 0
Cash On-Hand
Amount
Row 0, Column 0
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b. All financial accounts (List bank Name and Amount) * This field is required.
Bank Name
Amount
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Row 0, Column 0
Row 0, Column 1
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Row 1, Column 0
Row 1, Column 1
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Row 2, Column 0
Row 2, Column 1
1
2
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Bank Name
Row 0, Column 0
Amount
Row 0, Column 1
Bank Name
Row 1, Column 0
Amount
Row 1, Column 1
Bank Name
Row 2, Column 0
Amount
Row 2, Column 1
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c. Cars, Boats, and Other Vehicles
Make/Year
Fair Market Value
How Much You Still Owe
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Row 0, Column 0
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1
2
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Make/Year
Row 0, Column 0
Fair Market Value
Row 0, Column 1
How Much You Still Owe
Row 0, Column 2
Make/Year
Row 1, Column 0
Fair Market Value
Row 1, Column 1
How Much You Still Owe
Row 1, Column 2
Make/Year
Row 2, Column 0
Fair Market Value
Row 2, Column 1
How Much You Still Owe
Row 2, Column 2
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d. Real Estate
Complete Address
Fair Market Value
How Much Owed
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Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
1
2
Complete Address
Row 0, Column 0
Fair Market Value
Row 0, Column 1
How Much Owed
Row 0, Column 2
Complete Address
Row 1, Column 0
Fair Market Value
Row 1, Column 1
How Much Owed
Row 1, Column 2
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e. Other Personal PropertyJewelry, Furniture, Furs, Stocks, Bonds, Etc.
Describe
Fair Market Value
How Much Owed
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Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
1
2
Describe
Row 0, Column 0
Fair Market Value
Row 0, Column 1
How Much Owed
Row 0, Column 2
Describe
Row 1, Column 0
Fair Market Value
Row 1, Column 1
How Much Owed
Row 1, Column 2
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a. List any Payroll Deductions and the Monthly Amount Below:
Payroll Deductions
Amount
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Row 1, Column 0
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1
2
3
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Payroll Deductions
Row 0, Column 0
Amount
Row 0, Column 1
Payroll Deductions
Row 1, Column 0
Amount
Row 1, Column 1
Payroll Deductions
Row 2, Column 0
Amount
Row 2, Column 1
Payroll Deductions
Row 3, Column 0
Amount
Row 3, Column 1
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Amount
b. Rent or House Payments & Maintenance
Row 0, Column 0
c. Food and Household Supplies
Row 1, Column 0
d. Utilities and Telephone
Row 2, Column 0
e. Clothing
Row 3, Column 0
f. Laundry and Cleaning
Row 4, Column 0
g. Medical and Dental Expenses
Row 5, Column 0
h. Insurance (life, health, accident, etc.)
Row 6, Column 0
i. School, Child Care
Row 7, Column 0
j. Child, Spousal Support (another marriage)
Row 8, Column 0
k. Transportation
Row 9, Column 0
b. Rent or House Payments & Maintenance
c. Food and Household Supplies
d. Utilities and Telephone
e. Clothing
f. Laundry and Cleaning
g. Medical and Dental Expenses
h. Insurance (life, health, accident, etc.)
i. School, Child Care
j. Child, Spousal Support (another marriage)
k. Transportation
Amount
Row 0, Column 0
Amount
Row 1, Column 0
Amount
Row 2, Column 0
Amount
Row 3, Column 0
Amount
Row 4, Column 0
Amount
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Amount
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Amount
Row 7, Column 0
Amount
Row 8, Column 0
Amount
Row 9, Column 0
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l. Installment Payments (list each below)Paid To:
Company
How Much?
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Row 0, Column 0
Row 0, Column 1
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Row 1, Column 0
Row 1, Column 1
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Row 2, Column 0
Row 2, Column 1
1
2
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Company
Row 0, Column 0
How Much?
Row 0, Column 1
Company
Row 1, Column 0
How Much?
Row 1, Column 1
Company
Row 2, Column 0
How Much?
Row 2, Column 1
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m. Wages/Earnings withheld by Court Order:
$: Amount
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n. Any other monthly expenses (list each below)
Description
How Much?
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Row 0, Column 0
Row 0, Column 1
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Row 1, Column 0
Row 1, Column 1
3
Row 2, Column 0
Row 2, Column 1
1
2
3
Description
Row 0, Column 0
How Much?
Row 0, Column 1
Description
Row 1, Column 0
How Much?
Row 1, Column 1
Description
Row 2, Column 0
How Much?
Row 2, Column 1
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Total Monthly Expenses
$: Amount
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To list any other facts you want the court to know, such as unusual medical expenses, etc., attach form MC-025 or attach a sheet of paper and write Financial Information and your name and case number at the top.Important! If your financial situation or ability to pay court fees improves, you must notify the court within five days on form FW-010.
Click here if you attach another page.
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Verification of Pleading (Code Civ. Proc., § 446)

Declaration under Penalty of Perjury Form (Code Civ. Proc., §§ 446, 2015.5)

by Party
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Case Title(Case Name)
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I, Full Name declare: I am the Defendant or Plaintiff in the above-entitled matter. I have read the foregoing (pleading, e.g. complaint) and know the contents thereof.

The same is true of my own knowledge, except as to those matters which are therein stated on information and belief, and, as to those matters, I believe it to be true.

Executed on Date at Street Address City State Zip

I declare (or certify) under penalty or perjury that the following is true and correct.

Signature
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PLEASE SCREENSHOT THIS SCREEN FOR YOUR RECORDS!
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I, Name of Patient , hereby authorize Health Care Facility release the following health information:
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(Name and title or facility name to receive health information)Attorney's Legal Name
Twin-Oak Attorneys
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(Street address, city, state, ZIP code)Attorney's Address
21818 Craggyview St., STE 201, Chatsworth, CA 91311
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(Telephone number)Attorneys Phone Number
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(Fax number)Attorneys Fax Number
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For the following purposes
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This authorization is in effect until(date or event), when it expires.
Date
Month
Day
Year
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I understand that by signing this authorization:
I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.
I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
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Today's Date
Date
Month
Day
Year
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Or Signed by Personal Representative:
Representatives Full Name
On Behalf of
Name of Patient
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Signed by Patient/Representative
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COPY OF IDENTIFICATION ATTACHED
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ID Type
Please Select
Please Select
DMV CA Driver License
DMV CA Identification Card
Passport
Military ID
Green Card
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IDENTIFICATION CARD, BIRTH CERTIFICATE, BENEFITS IDENTIFICATION CARD, MANAGED CARE CARD, STATE OR FEDERAL EMPLOYEE ID CARDNumber
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IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.

NOT OFFICIAL UNLESS STAMPED BY NOTARY PUBLIC.
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NOTARIZED BY
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Notary Phone Number
Area Code
Phone Number
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Notary Email
example@example.com
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ON
Date
Month
Day
Year
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Notary Public Number
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What Legal Authority Do You Have to Make Medical Decisions for the Patient?
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
OTHER
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NOTE: ATTACHING LEGAL DOCUMENTATION IS REQUIRED TO VERIFY THAT YOU ARE THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR HAVE MEDICAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL.
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