Free 366-005 - Illinois

APPLICATION FOR REFUND
TRAFFIC TICKET NO. ___________________________ COURT DATE ______________________

PAID BY_______________________________________________________________________________________ ADDRESS _____________________________________________________________________________________ AUTO LICENSE NO. _____________________________ STATE ____________________ YEAR _______________ ISSUED TO: NAME ____________________________________________________________________________ ADDRESS _________________________________________________________________________ VEHICLE TAG NO. _____________________________ PREFIX ___________________ YEAR ______________ ISSUED TO: NAME ____________________________________________________________________________ ADDRESS _________________________________________________________________________ PAYMENT RECORD DATE ______________ TRANS. NO. __________________ REG. NO. ______________ AMOUNT $ ___________ DATE ______________ TRANS. NO. __________________ REG. NO. ______________ AMOUNT $ ___________ DATE ______________ TRANS. NO. __________________ REG. NO. ______________ AMOUNT $ ___________ FORMS ATTACHED PERSONAL ISSUE TICKET NO. __________________________________________________________________ COURT COPY OF PARKING TICKET NO. ___________________________________________________________ DEFENDANT'S COPY OF PARKING TICKET NO. ____________________________________________________ POLICE NOTICE OF PARKING TICKET NO. ________________________________________________________ SUMMONS NOTICE OF PARKING TICKET NO. ____________________________________________________ OTHER (SPECIFY) ______________________________________________________________________________

REASON FOR APPLICATION FOR REFUND
AMOUNT DUE $ ________________ AMT. PAID $ ________________ REFUND CLAIMED $ _______________

______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________
PREPARED BY ______________________________ CLERK SIGNED BY _________________________________ APPLICANT

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (6/9/03) 366*005