Free FIRST JUDICIAL DISTRICT OF PENNSYLVANIA - Pennsylvania

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: __________________________