Santa Clara — FM-1067*

Source: https://santaclara.courts.ca.gov/system/files/forms/fm-1067_rem.pdf

ATTACHMENT FM-1067 ATTORNEY OR PARTY WITHOUT AN ATTORNEY: TELEPHONE NUMBER: Name ATTACHMENT FM-1067

FOR COURT USE ONLY

Firm

Address:

e-mail

ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: 201 North First Street, San José, CA 95113

MAILING ADDRESS: 191 North First Street

CITY AND ZIP CODE: San José, California 95113

BRANCH NAME: Family Justice Center

PETITIONER:

RESPONDENT:

CLAIMANT: CASE NUMBER:

APPLICATION #:

APJ:

APPLICATION AND ORDER FOR PAYMENT OF ATTORNEY FEES AND COSTS OF CHILDREN’S COUNSEL DEPARTMENT:

I, , declare the following:

1. I am an attorney duly licensed to practice law within the State of California.

2. The last four digits of my tax ID number are: _________. My Phoenix vendor number is: _________________.

3. I am the Child(ren)’s Counsel in the above-entitled action. I was appointed on ,

by the Santa Clara County Superior Court to represent the following child(ren) in this matter:

.

4. I have timely filed the Declaration of Counsel for a Child Regarding Qualifications (JC Form #FL-322). I have

reviewed Rule 9 of the Family Local Rules of Court as well as the requirements in FM-1055 (Order Appointing Minor’s Counsel) and am making this request in compliance with the rules and guidelines therein. I have served this application, a blank response, and a blank Income and Expense Declaration on the parties and their attorneys, if applicable.

5. I, and/or my staff, have completed hours of work on this matter between the dates

   of and .

6. I am requesting fees in the amount of $ and costs in the amount of $ . I recommend that the court allocate the payment of such fees and costs as follows: % to be paid by Petitioner % to be paid by Respondent % to be paid by the Superior Court for the following reason(s):

FM-1067 REV 9/19/2025 APPLICATION FOR PAYMENT OF ATTORNEY FEES AND Page 1 of 3 For Mandatory Use COSTS OF CHILDREN’S COUNSEL

ATTACHMENT FM-1067

PETITIONER: CASE NUMBER:

RESPONDENT: APPLICATION #:

7. I request an order that if a party fails to make a full payment within 10 days of the due date ordered by

   the court, the entire balance will immediately become due with interest accruing at the legal rate from the date

   of default.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: Child(ren)’s Counsel

NOTICE:

To Child(ren)’s Counsel: You must submit this Application and Order through e-filing.

To the Parties: You must complete the form “Response to Application for Payment of Fees and Costs of Children’s Counsel (form FM-1068)” and follow the procedures set out in that form. Your response must be filed within 21 calendar days of the date of this application.

Failure to submit a response may result in an order directing you to pay up to 100% of the fees and costs requested.

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ATTACHMENT FM-1067

ORDER (TO BE COMPLETED BY THE COURT):

PETITIONER: CASE NUMBER:

RESPONDENT: APPLICATION #:

Having reviewed the request of the Children’s Counsel and any responses by the parties, the court issues the

following findings and orders:

FINDING OF INABILITY TO PAY: Upon review of all financial declarations and the Court file(s), the Court finds

Petitioner Respondent is/are unable to pay all part of the children’s attorney’s fees and costs.

1. Children’s Counsel, , will be paid $ in current fees

   and $ in costs for the period from to .

2. Petitioner is ordered to pay $____________. Payment will be made as follows:

   Late payments will accrue interest at the legal rate.

   Monthly payments in the amount of $ will commence on .

   If a monthly payment is late, the entire balance will be immediately due and interest will accrue at

   the legal rate.

   Other: .

3. Respondent is ordered to pay $____________. Payment will be made as follows:

   Late payments will accrue interest at the legal rate.

   Monthly payments in the amount of $ will commence on .

   If a monthly payment is late, the entire balance will be immediately due and interest will accrue at

   the legal rate.

   Other: .

4. $ will be paid by the Superior Court of California, County of Santa Clara.

Date: Judge/Commissioner of the Superior Court

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