Form I: 

Request for Waiver of Filing Fee

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If the filing fee for your petition is beyond your ability to pay, you may request to have some or all of the filing fee waived, or to make arrangements for partial payments over a period of time.

If you would like to pay the filing fee in 3 monthly installments complete the form below and return it with the first installment.

If you are paying in three installments, you don’t need to complete the fee waiver application.

Be sure to state how much of the filing fee you request to be waived and/or any special payment schedule you may wish to propose.

Failure to accurately complete the form may result in denial of your request.

TEAR OFF-----------------------------------------------------------------------------------------


Name: ____________________________ Phone: __________________________

Address:________________________________________________________________
_______________________________________________________________________.

I am unable to pay the entire filing fee all at once. I am requesting the payment of my filing fee in 3 monthly installments.

I understand that the fee arbitration will not proceed until the entire filing fee is paid.

Enclosed is my first payment of _____________________________

I will pay the remaining balance in 2 monthly payments.


__________________________________ _____________________
Signature Date

 

IN THE MATTER OF ATTORNEY’S FEE ARBITRATION
BEFORE THE BEVERLY HILLS BAR ASSOCIATION

In the Matter of the Arbitration between 

                                                                                
Petitioner

and

                                                                                
Respondent

                                                                                 
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DECLARATION FOR WAIVER 
OF THE ARBITRATION FILING FEE

The undersigned requests the Arbitration Committee to waive the filing fee for arbitration. The undersigned understands 
that the information provided in this application must be accurate and truthful. The undersigned further understands he/she may be required to submit records in support of this application.

I 
GENERAL INFORMATION

APPLICANT (Name)                                                   

Social Security No.                                                        

Occupation:                                                                    

Employer Name:                                                            

                                                                                     

Address:                                                                        

                                                                                      

Phone (Home)                                                               

Phone (Work)                                                               

 PRESENT SPOUSE (or live in companion) 
(Name)                                                                         

Social Security No.                                                        

Occupation:                                                                    

Employer Name:                                                            

                                                                                      

Address:                                                                        

                                                                                      

Phone (Home)                                                               

Phone (Work)                                                               
II FEE DISPUTE INFORMATION
(1)
(2)

(3)


(4)
(5)		 How much in total legal fees and costs has the attorney charged? 
How much of the above (if any) do you agree to as an appropriate
total attorney fee? 
How much of the attorney fees are in dispute? (1 minus 2): (NOTE: THE
AMOUNT IN DISPUTE LISTED HERE MUST AGREE WITH 
AMOUNT IN DISPUTE LISTED ON PETITION.) 
How much have you actually paid? 
When was last fee payment and how was payment made?                            		 $ ____________________

$ ____________________


$ ____________________
$ ____________________
                                           
(6) Please briefly indicate the nature of the legal problem and the services rendered by the attorney (e.g., family, criminal, probate, etc.) below. You do not need to discuss  in this application the reason you dispute the attorney’s fees.
                                                                                                                                                                            

                                                                                                                                                                            

                                                                                                                                                                           
(7) Filing Fee - To determine the filing fee normally payable in a case this size, please check page 1 of the Petition for Fee Arbitration and record fee here. 
$                                          
 
III MONTHLY INCOME AND EXPENCE STATEMENT
A  Monthly Income & Income Adjustments Applicant Spouse (Live-In)
(1) Gross Monthly income from:
Salary and Wages* (including commissions, bonuses and overtime)
$
$
Pensions and retirement benefits. $ $
Social Security $ $
Disability and unemployment insurance $ $
Public assistance (welfare, AFDC payments, etc.) $ $
Child/Spousal support $ $
Dividends and Interest $ $
All other sources (i.e., rent, etc.) $ $
Total Monthly Income $ $

Total Monthly Income

 $ $
(2) Itemize deductions from gross income: $ $
Income taxes (state and federal) $ $
Social Security (FICA) $ $
Medical or other insurance $ $
Union or other dues $ $
Retirement or pension fund $ $
Savings plan $ $
Other: (specify) $ $
$ $

Total Monthly Income

 $ $

Net Monthly take-home income 1 - 2

 $ $

*If unemployed, explain why                                                                                                                                

                                                                                                                                                                            
Total Monthly Expenses:

List name, age, and relationship of all members of the household whose expenses are included. (If separated or 
divorced, indicate any of the below expenses spouse pays - listing the amount.)                                                                                                                                                                              

                                                                                                                                                                            
(1) General Monthly Expenses: Applicant Spouse (Live-In)
Rent or mortgage payments (including property taxes 
and homeowner insurance)
$
$
Food $ $
Utilities and telephone $ $
Clothing $ $
Medical and dental (unreimbursed) $ $
Insurance (life, health, accident, etc.) $ $
Child Care $ $
My payment of child/spousal support $ $
Entertainment. $ $
Incidentals $ $
Transportation and auto expenses (insurance, gas,
oil, repair but not including loan payments).
$
$
Auto Loan. $ $
Auto Maintenance $ $
Total installment payments (itemize below) $ $
All Other (itemize) $ $
$ $
$ $
$ $

Total Monthly Expences

 $ $

 

(2) Installment Payments
Creditor For Monthly Payment Balance
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Total Installment Payments $
(3) Credit Cards
Creditor Credit Limit Monthly Payment Balance
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Total Credit Card Payments $
$ $
IV ASSETS Applicant Spouse (Live-In)
Cash on Hand $ $
Checking accounts $ $
Savings accounts $ $
Auto/truck (make & year) $ $
Other vehicles $ $
Home $ $
Other real estate $ $
Furniture and appliances $ $
Stocks and bonds $ $
Pension and retirement funds. $ $
Life insurance cash value $ $
Other. $ $
$ $
$ $
$ $
TOTAL PROPERTY: $ $
For any property listed above which is subject to any obligations or loans not already described, specify the following: Value of Amount of
Asset (Describe) Value of Asset Amount of Obligation or Loan
$ $
$ $
$ $
$ $
$ $
Total: $ $
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA 
THAT THE INFORMATION LISTED IN THIS FORM IS TRUE AND CORRECT, AND THAT THIS 
DECLARATION WAS COMPLETED ON:

____________________________________________ at ____________________________________
(Date) (Address) 

If the proceeding results in an award in my favor ordering payment of any amount to me by the other party, I agree 
to pay the Beverly Hills Bar Association Fee Arbitration Program the amount of the waived fee unless the award provides otherwise. By my signature below, I agree that I have read, understand and agree to these terms.


Sign your name(s) here:

_____________________________________________ __________________________________________


_____________________________________________ 
PRINTED NAME



Date:_________________________________________



Mail to: 
Beverly Hills Bar Association
300 S. Beverly Drive, Suite 201
Beverly Hills, CA 90212

310.553.6644 Tel
310.284.8290 Fax


IF THIS DOCUMENT IS FAXED, WE MUST RECEIVE THE DOCUMENT WITH AN ORIGINAL 
SIGNATURE ON IT WITHIN 5 DAYS OR YOUR REQUEST WILL NOT BE CONSIDERED


© COPYRIGHT 2002 BEVERLY HILLS BAR ASSOCIATION