Free G-ACN-WIT - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type:

Select County

Plaintiff

vs.

Application for Reimbursement of Witness Expenses

Defendant

I am the parent of a minor called as a witness for ___________________________________ regarding the above case.
Party Who Called You or Your Child as a Witness

I was called as a witness or

I am claiming witness fees and/or reimbursement as follows: NOTE: Total amount reimbursed for meals, loss of wages and child care may not exceed $60 per day. Do not submit a claim for any of these expenses without providing written proof of lost wages from your employer and receipts for other expenses. Date Appeared Daily Fee (Witness Only) Child Care Mileage (# of Miles X $0.28) Lost Wages Meals Daily Totals

TOTAL CLAIMED: $ VERIFICATION I declare under the penalties of perjury that I am the person making this claim; that I have examined the claim and it is just and true; that the expenses were actually paid for the purposes stated and that the fees are allowed by law; and that no part of the claim has been paid. Dated: ______________ __________________________________________________
Signature

Name: ____________________________________________ Street Address: _____________________________________ City/State/Zip: _____________________________________ Social Security # (required for payment): ______________________

OFFICE USE ONLY Amount of claim $ Less amount claim exceeds statutory allowance - $ Less expenses not proven in writing - $ Amount approved for payment $ Dated:

FY____ ORG _____ APPR ______ 2M01 100 09

Deputy Court Administrator
CRM402 State ENG Rev 8/07 www.mncourts.gov/forms Page 1 of 1