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CIV -11( <br />PLAINTIFF/PETITIONER: FRANCESCA FAMBROUGH, at al. CASE NUMBER: <br />DEFENDANT/RESPONDENT: CITY OF REDWOOD CITY 17CIV05387 <br />COURT'S RECOVERY OF WAIVED COURT FEES AND COSTS <br />If a party whose court fees and costs were initially waived has recovered or will recover $10,000 or <br />more in value by way of settlement, compromise, arbitration award, mediation settlement, or other <br />means, the court has a statutory lien on that recovery. The court may refuse to dismiss the case until <br />the lien is satisfied. (Gov. Code, § 68637.) <br />Declaration Concerning Waived Court Fees <br />1. The court waived court fees and costs in this action for (name): <br />2. The person named in item 1 is (check one below): <br />a. ❑ not recovering anything of value by this action. <br />b. ❑ recovering less than $10,000 in value by this action. <br />c. ❑ recovering $10,000 or more in value by this action. (if item 20 is checked, item 3 must be completed.) <br />3. ❑ All court fees and court costs that were waived in this action have been paid to the court (check one): ❑ Yes ❑ No <br />I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. <br />Date: <br />(AAAA- <br />(TYPE <br />AA -(TYPE OR PRINT NAME OF ❑ ATTORNEY ❑ PARTY MAKING DECIARATION) (SIGNATURE) <br />CIV -110 [Rev. January 1, 2013] REQUEST FOR DISMISSAL Page 2 of 2 <br />