Municipal D.U.I. Report City of _______________________________ Case No. Style of Case Amount of Costs Collected I hereby certify that the foregoing is a true, correct and complete report on one-half of costs collected, as required by 28 O.S. §153.1, during the monthly period ending _______________________, 20_____. Dated and subscribed at _______________________ (city), Oklahoma, this ______ day of __________________, 20_____. ________________________________ Court Clerk ________________________________ Deputy The original and voucher, made payable to City Court Clerk, may be transmitted to City Court Clerk. Second copy is retained by District Court Clerk. AOC Form 41 Revised 7/05 American LegalNet, Inc. www.USCourtForms.com