SDSC ADM-243 (New 5/09) PERSONAL INFORMATION SHEET RE: ORDER TO REIMBURSE THE COURT MINOR222S COUNSEL FEES (CONFIDENTIAL) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 FOR COURT USE ONLY PETITIONER (S) RESPONDENT(S) THIRD PARTY PERSONAL INFORMATION SHEET RE: ORDER TO REIMBURSE THE COURT MINOR222S COUNSEL FEES (CONFIDENTIAL) CASE NUMBER You were ordered to reimburse the San Diego Superior Court for the fees and costs paid by the court to the attorney for your minor child[ren]. You were notified that payment dates would be set and separate statements indicating both the amount and date due would be mailed to you. The following information is required for purposes of billing and will be kept confidential. Please print and provide current information. It is your responsibility to inform the court of any changes to your mailing address. Petitioner Respondent Third Party Last Name: First Name: M.I.: Mailing Address: City: State: Zip Code: Telephone Number: ( ) (home) ( ) (work) ( ) (cell) Driver222s License Number: State: Date of Birth: Social Security Number: - - Date: Signature NOTICE Any party required to pay court-ordered attorney222s fees and costs or to reimburse the court for attorney222s fees and costs paid on a party222s behalf must pay interest on amounts more than 30 days past due at the legal rate, which is currently 10% per year. Failure to pay court-ordered attorney222s fees and costs or reimburse the court for fees and costs paid on a party222s behalf may result in a legal action being initiated to collect overdue payments and interest on overdue amounts. The information provided, including your Social Security number, may be used as an aid in identification should it become necessary to pursue collection of any unpaid amounts. American LegalNet, Inc. www.FormsWorkFlow.com