APPLICATION FOR REFUND TRAFFIC TICKET NO. ___________________________ COURT DATE ______________________ PAID BY_______________________________________________________________________________________ ADDRESS _____________________________________________________________________________________ AUTO LICENSE NO. _____________________________ STATE ____________________ YEAR _______________ ISSUED TO: NAME ____________________________________________________________________________ ADDRESS _________________________________________________________________________ VEHICLE TAG NO. _____________________________ PREFIX ___________________ YEAR ______________ ISSUED TO: NAME ____________________________________________________________________________ ADDRESS _________________________________________________________________________ PAYMENT RECORD DATE ______________ TRANS. NO. __________________ REG. NO. ______________ AMOUNT $ ___________ DATE ______________ TRANS. NO. __________________ REG. NO. ______________ AMOUNT $ ___________ DATE ______________ TRANS. NO. __________________ REG. NO. ______________ AMOUNT $ ___________ FORMS ATTACHED PERSONAL ISSUE TICKET NO. __________________________________________________________________ COURT COPY OF PARKING TICKET NO. ___________________________________________________________ DEFENDANT’S COPY OF PARKING TICKET NO. ____________________________________________________ POLICE NOTICE OF PARKING TICKET NO. ________________________________________________________ SUMMONS NOTICE OF PARKING TICKET NO. ____________________________________________________ OTHER (SPECIFY) ______________________________________________________________________________ REASON FOR APPLICATION FOR REFUND AMOUNT DUE $ ________________ AMT. PAID $ ________________ REFUND CLAIMED $ _______________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ PREPARED BY ______________________________ CLERK SIGNED BY _________________________________ APPLICANT DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (6/9/03) 366*005 Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form