Superior Court of California County of San Francisco REQUEST FOR JURY FEE DEPOSIT REFUND Within 20 business days from the date on which the jury is waived or the action is settled, dismissed, or a continuance thereof granted, a requesting party may submit a written request for refund of the posted jury fee deposit amount of $150.00 provided said deposit was made after January 1, 1999 and prior to June 27, 2012. Name ____ Address _________________________________________________________________________ Refund amount requested _____________________________________ ___ Date of request ___ Date of posting jury fee deposit* *Only jury fee deposits made after January 1, 1999 and prior to June 27, 2012 are refundable. Transaction/Fee Tag Number(s) Case Number/Title Attach supporting documentation confirming California Code of Civil Procedure Sect. 631.3(a) compliance as failure to provide documentation will result in a denial of the refund: _____ _____ _____ _____ _____ Jury was waived (declaration required) Notice of settlement filed Dismissal filed Case set for Order to Show Cause for CRC 3.1385 compliance Case continued in trial department, no jury summoned (declaration required) The amount claimed is justly due and this claim has been presented and received by the Accounting Department originally receiving said money within the time prescribed by law. I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION STATED ABOVE IN THIS FORM IS TRUE AND CORRECT. EXECUTED ON AT , CALIFORNIA. ______________________________________ SIGNATURE OF CLAIMANT DEPARTMENTAL USE ONLY Refund request approved/denied on the basis of: Amount to be refunded: Date (DL) 415-551-5718 Division Manager Authorization 400 McAllister Street, Room 103 San Francisco, CA 94102-4514 Attention: Accounting FAX 415-551-3801 American LegalNet, Inc. www.FormsWorkFlow.com