Agreed Petition for Refund of Fees Collected (03/18/16) CCG N052 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS v. Case No. AGREED PETITION FOR REFUND OF FEES COLLECTED I, __________________________________________, hereby petition this honorable Court to order the refund of certain fees and costs collected by the Clerk of the Circuit Court of Cook County. __________________________________________ delivered $ __________ in payment of fees and/or costs to the Clerk of the Circuit Court in payment of __________________________________________ on _________. It has been determined that $ __________ of this payment was not due and owing to the Clerk of the Circuit Court. The petitioner hereby declares that the foregoing statements to be true and accurate. By ORDER It is therefore ordered DOROTHY BROWN, Clerk of the Circuit Court pay to __________________________ the amount of $ _________ as a refund of the fees and/or costs. Atty. No.: ________________ Name: Atty for: Address: City: ______________________ Primary Email: Secondary Email: Tertiary Email: IL State: ____ Entered Date: ___________ Zip: ________ Judge Judge's No. Telephone: ________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com