NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk's File Stamp 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: $__________ Depositor: Address: Receipt #: ___________ ______________________________________ Printed Name _________________________________________________________________________________________ Number Street City State Zip Dated: ___________________ Signature: _____________________ TO BE COMPLETED BY THE COURT: Request for Refund: Refund: Approved Requires judicial approval Denied Requires manager's approval only Refund #: __________________ Dated: ____________________ By: ________________________________________ Judicial Officer/Manager's Signature ________________________________________ Printed Name LACIV 150 (Rev. 03/15) LASC Approved 09-05 For Optional Use REQUEST FOR REFUND American LegalNet, Inc. www.FormsWorkFlow.com