Free Request for Refund - California

NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE BAR NUMBER

Reserved for Clerk's File Stamp

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
COURTHOUSE ADDRESS: PLAINTIFF: DEFENDANT:

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CASE NUMBER:

REQUEST FOR REFUND
NOTE: THIS FORM IS NOT TO BE USED FOR REFUND OF JURY FEES. [Use Declaration and Order Re: Advance Jury Fees, LASC Approved LACIV 099, to request refund of jury fee deposit.] I am requesting a refund in the amount of $ _________________ for the following reasons: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Date of payment/deposit: ________________ Amount Paid: $__________ Depositor: Address: Receipt #: ___________

______________________________________ Printed Name _________________________________________________________________________________________ Number Street City State Zip Dated: ___________________

Signature: _____________________
TO BE COMPLETED BY THE COURT:

Request for Refund: Refund: Approved

Requires judicial approval Denied

Requires manager's approval only

Refund #: __________________ Dated: ____________________

By: ________________________________________
Judicial Officer/Manager's Signature

________________________________________
Printed Name

LACIV 150 (Rev. 01/07)
LASC Approved 09-05

REQUEST FOR REFUND
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