Trinity — Court Claim Form

Source: https://www.trinity.courts.ca.gov/system/files/court-claim-form.pdf

Claimant's Name: TRINITY SUPERIOR COURT Attn: State of California Street or Box No.: Claim/Authorization for Release of Funds City and State: Zip: Dept. Contract Information Vendor # Contract# Date: Contract Exp. Ins. Exp.

COUNTY CUSTOMER INVOICE INFORMATION
Transaction Customer I.D. Invoice # Total Invoice
Amount Dept# Acct # Job Code (30 Spaces Available) (16 Spaces Avail)

CLAIMS FOR REIMBURSEMENT MUST
BE SUBMITTED NO LATER THAN
QUARTERLY WITHIN 30 DAYS OF THE
MONTH OR QUARTER BEING BILLED.

Transaction Total Invoice Total

I HEREBY CERTIFY that the above claim and the items, amounts and I HEREBY CERTIFY upon my own personal knowledge that the articles

statements as herein set out are true and correct; that no part thereof or services specified in the above claim were necessary & were ordered by

has been heretofore paid; that the amount is justly due and is me for the purpose indicated hereon; that the articles have been delivered

presented within one year after the last item thereof has accrued. or the services have been performed by the claimant as set forth with the

exceptions noted. Claim is thereby approved.

Signed _________________________________________________ Signed________________________________________________________ Claimant Approving Signature

SEC. #910.2 GOVT. CODE LF-002