SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BANNING 135 N. Alessandro Rd., Banning, CA 92220 BLYTHE 265 N. Broadway, Blythe, CA 92225 HEMET 880 N. State St., Hemet, CA 92543 MORENO VALLEY 13800 Heacock St., Ste. D201, Moreno Valley, CA 92553 $77251(< 25 3$57< :,7+287 $77251(< (Name, State Bar Number and Address MURRIETA 30755-D Auld Rd., Ste. 1226, Murrieta, CA 92563 PALM SPRINGS ( 7DKTXLW] &DQ\RQ :D\ 3DOP 6SULQJV &$ RIVERSIDE 4050 Main St., Riverside, CA 92501 5,3 FOR COURT USE ONLY 7(/(3+21( 12 (0$,/ $''5(66 (Optional): $77251(< )25 (Name )$; 12 (Optional): PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: Hearing Date: Time: CASE NUMBER: Department: DECLARATION AND ORDER FOR REFUND OF MONIES ON DEPOSIT Do not apply a refund of money on deposit if said money was ordered refunded in open court. has been filed has not been filed Dismissal Declarant states: I am the attorney for the and have heretofore deposited the sum of $ with the clerk herein for the purpose(s) of: Caution: A refund of said money to declarant is proper because (state reason for refund): I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Date: (TYPE OR PRINT NAME OF ATTORNEY PARTY MAKING DECLARATION) (SIGNATURE) Amount of $ on deposit verified on The clerk is authorized to refund to the declarant the sum of $ CLERK-SUPERIOR COURT by , Deputy (JUDGE OF THE SUPERIOR COURT) Approved for Optional Use Riverside Superior Court RI-P01 [Rev. 07/29/13] DECLARATION AND ORDER FOR REFUND OF MONIES ON DEPOSIT riverside.courts.ca.gov/localfrms/localfrms.shtml Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com