Free Application For Refund of Fees Paid Electronically Through Pay.gov - Georgia

APPLICATION FOR REFUND OF FEES PAID ELECTRONICALLY THROUGH PAY.GOV

Date of Request: Case Number: Amount to be Refunded: Reason for Request:

Date of Fee Payment: Receipt Number:

Supervisor's Recommendation:

Action Taken:

_______ _______ _______

Approved Denied Referred to Judge for further action

__________________________ DATE

_______________________________________ JAMES N. HATTEN Clerk of Court