CIV-110 Request for Dismissal

Declaration Concerning Waived Court Fees
PLAINTIFF/PETITIONER:
CASE NUMBER:
DEFENDANT/RESPONDENT:
CIV-110
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):
3.
2.
The person named in item 1 is (check one below):
not recovering anything of value by this action.
a.
recovering less than $10,000 in value by this action.
b.
recovering $10,000 or more in value by this action. (If item 2c is checked, item 3 must be completed.)
c.
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.
Date:
ATTORNEY(TYPE OR PRINT NAME OF
(SIGNATURE)
PARTY MAKING DECLARATION)
Yes No
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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