Los Angeles local civil form — Request for Refund (LASC LACIV 150)

Source: https://lascpubstorage.blob.core.windows.net/forms/Forms%20Comprehensive%20List/LASC%20LACIV%20150.pdf

NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk’s File Stamp

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES

COURTHOUSE ADDRESS:

PLAINTIFF:

DEFENDANT:

CASE NUMBER:

REQUEST FOR REFUND

(BeginNOTE: Underline)THIS FORMDeclarationISUnderline),, SCLACNOT TOApprovedBE USEDLACIVFOR099,REFUNDto requestOFrefundJURYof juryFEES.fee deposit.][Use (Begin Underline) Declaration

IF YOU ARE REQUESTING A REFUND FOR A FEE PAID THROUGH THE COURT RESERVATION SYSTEM (CRS), attach documentation which substantiates that the court erred in calculating or processing a fee.

I am requesting a refund in the amount of $ _________________ for the following reasons:

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Date of payment/deposit: ________________ Amount Paid: $__________ Receipt #: ___________

Depositor: ______________________________________ Printed Name Address: _________________________________________________________________________________________ Number Street City State Zip Signature: _____________________SIGN Dated: ___________________

TO BE COMPLETED BY THE COURT:

Request for Refund: Requires judicial approval Requires manager’s approval only

Refund: Approved Denied Refund #: __________________

By: ________________________________________SIGN Dated: ____________________ Judicial Officer/Manager’s Signature

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Printed Name

LACIV 150 (Rev. 04/26)
SCLAC Approved 04-26 REQUEST FOR REFUND
For Optional Use
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