Superior Court of California County of San Francisco Request for Refund Name of Claimant (please print) Address of Claimant Email Address of Claimant Amount requested to refund Date(s) of Transaction Transaction/Fee Tag Number(s) Case Number/Title Please note: The Court will follow up by email with information or questions regarding this request. Reason for request of refund: (This is required for consideration of merit, attach a separate sheet if additional space is needed.) The amount claimed is justly due and this claim has been presented and filed with the department originally receiving said money within the time prescribed by law. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. EXECUTED ON SIGNATURE OF CLAIMANT DEPARTMENTAL USE ONLY Refund request approved/denied on the basis of: AT , CALIFORNIA. Amount to be refunded: Date Division Manager/Senior Fiscal Technician Authorization 400 McAllister Street, Room 103 San Francisco, CA 94102-4514 Attention: Accounting FAX 415-551-3801 American LegalNet, Inc. www.FormsWorkFlow.com ARevenue@sftc.org