Pay.Gov Application For Refund
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Pay.Gov Application For Refund Form. This is a California form and can be use in USDC Northern Federal.
Loading PDF...
Tags: Pay.Gov Application For Refund, California Federal, USDC Northern
USDC-CAND http://cand.uscourts.gov PAY.GOV APPLICATION FOR REFUND – Version 1.1 – 01/11/2012
USDC-CAND PAY.GOV APPLICATION FOR REFUND
Today's Date
Account Holder Name
Account Holder Billing Address
Account Holder Billing City
Account Holder Billing State
Account Holder Billing Zip
Requestor’s Telephone Number
Requestor’s E-mail Address
Pay.gov Tracking ID (number)
Agency Tracking ID (number)
Transaction Date
Transaction Time
Transaction Amount (to be refunded)
Purpose of Payment/Fee
Full Case Number (if applicable)
Reason for Refund Request
•
•
The information required above can be found in the Pay.gov Screen Receipt or the Payment Confirmation e-mail.
For information on submitting this form to the court, see: https://ecf.cand.uscourts.gov/cand/faq/paygov.htm
For U.S. District Court use only.
Refund Request
APPROVED:
DENIED:
Refund Approved By
Pay.gov Refund Tracking ID Refunded
Agency Refund Tracking ID Number
Date Refund Processed
Refund Processed By
Reason for Denial
Referred for OSC
American LegalNet, Inc.
www.FormsWorkFlow.com
