Yuba — G25081

Source: https://www.yuba.courts.ca.gov/system/files/forms-and-filings/g25081-general-claim-form.pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF YUBA

GENERAL CLAIM FORM Page 1 of

CLAIMANT'S NAME SSN OR TAX ID NUMBER

POSITION/TITLE E-MAIL ADDRESS

PHYSICAL ADDRESS TELEPHONE NUMBER

CITY STATE ZIP CODE VENDOR NUMBER

MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL ADDRESS)

CITY STATE ZIP CODE

MONTH/DAY/YEAR QUANTITY DESCRIPTION UNIT PRICE AMOUNT

CLAIM TOTAL

CERTIFICATE OF CLAIMANT COURT USE ONLY

I hereby declare under penalty of perjury that the services or items claimed herein have been performed or delivered, that I have not been INVOICE DATE reimbursed or claimed reimbursement from any other agency for these services/items, and that this Claim Form is true and correct as stated. SIGN INVOICE AMOUNT

Date Signature INVOICE NUMBER

COURT APPROVAL

DOCUMENT NUMBER

I hereby certify that the services or goods set forth above were requested by authorized court personnel, that the services or goods were delivered or performed.

CHECK NUMBER

Date Signature

I hereby approve payment of this Claim Form.

Date Signature G25081 Effective 08/01/2025