State of Minnesota County Judicial District: Court File Number: Case Type: District Court Plaintiff vs. Defendant Application for Reimbursement of Witness Expenses I am the parent of a minor called as a witness for ___________________________________ regarding the above case. Party Who Called You or Your Child as a Witness I was called as a witness or I am claiming witness fees and/or reimbursement as follows: NOTE: Total amount reimbursed for meals, loss of wages and child care may not exceed $60 per day. Do not submit a claim for any of these expenses without providing written proof of lost wages from your employer and receipts for other expenses. Daily Fee Mileage Date Daily (Witness Child Care (# of Miles Lost Wages Meals Appeared Totals Only) X $0.28) TOTAL CLAIMED: $ VERIFICATION I declare under the penalties of perjury that I am the person making this claim; that I have examined the claim and it is just and true; that the expenses were actually paid for the purposes stated and that the fees are allowed by law; and that no part of the claim has been paid. Dated: ______________ __________________________________________________ Signature Name: Street Address: City/State/Zip: County : Telephone Number: E-mail address: Social Security # (required for payment): OFFICE USE ONLY Amount of claim $ Less amount claim exceeds statutory allowance - $ Less expenses not proven in writing -$ Amount approved for payment $ Dated: Deputy Court Administrator CRM402 State ENG Rev 7/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com FY____ ORG _____ APPR ______ 2M01 100 09 Page 1 of 1