Request For Refund
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1Reserved for Clerk’s File Stamp
NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE BAR NUMBER
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
COURTHOUSE ADDRESS:
PLAINTIFF:
DEFENDANT:
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.]
IF YOU ARE REQUESTING A REFUND FOR A FEE PAID THROUGH THE COURT RESERVATION SYSTEM
(CRS), attach documentation which substantiates that the court erred in calculating or processing a fee.
I am requesting a refund in the amount of $ _________________ for the following reasons:
_________________________________________________________________________________
_________________________________________________________________________________
Date of payment/deposit: ________________ Amount Paid: $__________
Receipt #: ___________
Depositor:
______________________________________
Printed Name
Address:
_________________________________________________________________________________________
Number
Street
City
State
Zip
Signature: _____________________
Dated: ___________________
TO BE COMPLETED BY THE COURT:
Requires manager’s approval only
Request for Refund:
Requires judicial approval
Refund:
Approved
Denied
Refund #: __________________
By: ________________________________________
Dated: ____________________
Judicial Officer/Manager’s Signature
________________________________________
Printed Name
LACIV 150 (Rev. 03/15)
REQUEST FOR REFUND
LASC Approved 09-05
For Optional Use
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