USCDNH-100 (01/13) (Rev. 09/14) UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE ~ REQUEST FOR REFUND OF ERRONEOUS OR DUPLICATE FEE PAID THROUGH PAY.GOV ATTORNEY NAME: ATTORNEY ADDRESS: Dear Clerk of Court, On : I electronically filed a Petition for Admission to Practice through Pay.Gov and, during the filing process, paid the same fee twice or paid the fee when none was due. I electronically filed a request for a Certificate of Good Standing through Pay.Gov and, during the filing process, paid the same fee twice or paid the fee when none was due. I hereby request a refund of my erroneous or duplicate fee in the amount of $, receipt number . /s/ American LegalNet, Inc. www.FormsWorkFlow.com