FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA OFFICE OF THE PROTHONOTARY PROTHONOTARY REFUND APPLICATION
Return to: ROOM 282 CITY HALL PHILADELPHIA PA 19107 or Fax to 215-686-3793 NAME AND ADDRESS OF PAYEE: ________________________________ ________________________________ ________________________________ ________________________________ Amount of Refund Request: $______________________________ APPROVED BY: _______________________________ Prothonotary, Finance Dept.
CASE CAPTION: ________________________________
Court Term & Number: _______________________________
VS. ________________________________ STATEMENT OF FACTS: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Note: Please attach your original cash register receipt or proof of payment, along with a copy of the civil docket report. PAYEE'S SIGNATURE:
________________________________ Date: __________________________