San Francisco — Request For Refund

Source: https://sf.courts.ca.gov/system/files/sfacc-003-request-refund.pdf

Superior Court of California COUNTY OF SAN FRANCISCO

400 McAllister Street, San Francisco, CA 94102 Phone: 415-551-4000 | Website: https://sfsuperiorcourt.org

REQUEST FOR REFUND

Name of Claimant (please print): Address of Claimant: Email Address of Claimant: Amount requested to refund: Date(s) of Transaction: Transaction/Fee Tag Number(s): Case Number/Title:

Please note: The Court will follow up by email with information or questions regarding this request.

Reason for request of refund: (This is required for consideration of merit, attach a separate sheet if additional space is needed.)

The amount claimed is justly due and this claim has been presented and filed with the department originally receiving said money within the time prescribed by law. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. EXECUTED ON AT , CALIFORNIA.

Signature of Claimant

FOR COURT USE ONLY

Refund request approved/denied on the basis of:

Amount to be Refunded:

Date: Division Manager/Senior Fiscal Technician Authorization

Attention: Accounting | 400 McAllister Street, Room 205, San Francisco, CA 94102 | ARevenue@sftc.org | Fax 415-551-5701

SFACC-003 Rev. Feb-21-2020