Declaration Concerning Waived Court Fees
The court waived court fees and costs in this action for (name):1.
All court fees and court costs that were waived in this action have been paid to the court (check one):
The person named in item 1 is (check one below):
not recovering anything of value by this action.
recovering less than $10,000 in value by this action.
recovering $10,000 or more in value by this action. (If item 2c is checked, item 3 must be completed.)
REQUEST FOR DISMISSAL
CIV-110 [Rev . Janu ar y 1, 20 13]
Page 2 of 2
I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.
ATTORNEY(TYPE OR PRINT NAME OF
PARTY MAKING DECLARATION)
COURT'S RECOVERY OF WAIVED COURT FEES AND COSTS
If a party whose court fees and costs were initially waived has recovered or will recover $10,000 or
more in value by way of settlement, compromise, arbitration award, mediation settlement, or other
means, the court has a statutory lien on that recovery. The court may refuse to dismiss the case until
the lien is satisfied. (Gov. Code, § 68637.)
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