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 COURT ADDRESS: PLAINTIFF: DEFENDANT: DECLARATION AND ORDER RE: ADVANCE JURY FEES CASE NUMBER: Declarant states: 1. I, _______________________________________________, deposited advance jury fees in the amount of (name) $ , receipt number _______________ on behalf of plaintiff defendant on [date(s)] ________________________, ________________________, in the above-entitled case. 2. 3. The aforementioned deposited jury fees have not been applied as payment for services of jurors and have not been previously ordered refunded or forfeited in this case. This case was never set for trial. This case was set for trial on the following date(s) (include all continued settings - attach sheet if necessary): On all the trial dates listed above wherein jury trial was continued, vacated, or otherwise not held due to request, agreement or jury waiver of this party, the court was notified by 2:00 p.m. of the previous court day in accordance with subdivision (e) of Rule 5.0 of the Los Angeles Superior Court Local Rules and Section 631.3 of the Code of Civil Procedure that a jury would not be needed for the trial. On all the trial dates listed above in which jury trial was continued, vacated, or otherwise not held, it was not by request, agreement or jury waiver of this party. LACIV 099 (Rev. 01/07) LASC Approved 04-05 DECLARATION AND ORDER RE: ADVANCE JURY FEES Page 1 of 2 Code Civ. Proc., § 631.3 Local Rule 5.0(e) American LegalNet, Inc. www.FormsWorkflow.com PLAINTIFF(S): CASE NUMBER: DEFENDANT(S): 4. A refund of the fees deposited as shown in item 2 above is proper because (explain in narrative what happened relative to a jury on each trial date set and continued in this case, e.g., on whose motion or request was the trial not held on the date set and did your side agree? When and how did the court know a jury would not be required on each date set? Was a panel called? Was the jury excused after arriving in the trial department? Did the other side pay any jury fees? See Rule 5.0, subdivision (e), of the Los Angeles Superior Court Local Rules and Section 631.3 of the Code of Civil Procedure.): I declare under penalty of perjury under the laws of the State of California, that the foregoing is true and correct. Dated: ______________________ _____________________________________________ (Signature of Declarant) _____________________________________________ (Address) __________________________________________________ (City, State, Zip) ORDER After giving due consideration to the above request, the court hereby orders as follows: This case having been set for trial, the court finds the depositor did did not was not required to give notice to the court under Section 631.3 of the Code of Civil Procedure and subdivision (e) of Local Rule 5.0 in sufficient time to notify the jurors that the trial would not proceed at the time set. The court finds this request has has not been made within 20 court business days of jury waiver, dismissal, settlement or granting of continuance of trial herein. Good cause appearing, the Clerk is ordered to refund to the declarant(s) forfeit the jury fees deposited by him/her/them in the sum of $_________________________________. Dated: _________________________ _______________________________________________ Judicial Officer LACIV 099 (Rev. 01/07) LASC Approved 04-05 DECLARATION AND ORDER RE: ADVANCE JURY FEES Page 2 of 2 Code Civ. Proc., § 631.3 Local Rule 5.0(e) American LegalNet, Inc. www.FormsWorkflow.com