Mariposa — Claim for Money Held

Source: https://www.mariposa.courts.ca.gov/system/files/claim-money-held_1.pdf

Superior Court of California County of Mariposa 5088 Bullion Street Post Office Box 316 Mariposa, CA 95338

CLAIM FOR MONEY HELD

MAIL TO: Superior Court of California, County of Mariposa, Administration Department, Post Office Box 316, Mariposa, CA 95338.

DATE SUBMITTED:

OWNER’S NAME (AS HELD BY COURT):

STREET ADDRESS:

CITY, STATE, ZIP CODE:

AMOUNT OF CLAIM: $

CLAIMANT’S NAME (MUST MATCH AFFIRMATION FORM):

RELATIONSHIP TO OWNER:

REASON FOR CLAIM:

A SEPARATE FORM IS REQUIRED FOR EACH ACCOUNT CLAIMS.

AFFIRMATION AND SIGNATURE (by Claimant): I hereby affirm, under penalty of perjury, that I am duly authorized to make said claim upon the Superior Court of California, County of Mariposa. I hereby agree to indemnify and hold harmless the state, the courts, and their officers and employees from any loss, including attorney's fees, incurred as a result of payment of the amount claimed.

Signature: ___________________________________________ Date: _________________________

COURT’S USE ONLY _____ Approved _____ Denied, Not an Authorized Claim

By: ________________________________________________ Date: _________________________

Local form for Mandatory Use Mariposa Super Court MISC-005 (04/29/22)