Superior Court of California, County of Alameda ___________________________________ Plaintiff Case No. _____________________ vs ___________________________________________________ Dept. No. _______________________ Defendant DECLARATION AND ORDER FOR PAYMENT OF MONEY (Jury Fee Deposit) This Declaration and Order for Payment is presented pursuant to and in conformity with the Rules of the Superior Court of California, County of Alameda. Jury fees have been posted in strict compliance with CCP 631 et seq in the above captioned action. They have not previously been ordered refunded or forfeited and they are eligible for refund pursuant to 631 et seq. I declare under penalty of perjury under the law of the State of California that the forgoing is true and correct. Receipt No.: ______________________________ Dated: ______________________ It is ordered that the sum of $ ________________________ as deposited above be paid to: Claimant: ____________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________________ Executed at: _______________________________________, California, on _____________________________ ____________________________________________ Claimant/Declarant Jury Fee Deposit Eligible for Refund Request is over 20 days from date case settled/dismissed/continued ­ Not Elibible for Refund Jury Fee Refunded on ______________ Verified by: ___________________________________________________ Date: ______________________ ORDER FOR PAYMENT OF MONEY Order Granted Order Denied Dated: ________________________ ______________________________________________ Judge of the Superior Court American LegalNet, Inc. www.FormsWorkFlow.com