Lassen — Public Transit Reimbursement Request

Source: https://www.lassen.courts.ca.gov/system/files/local-forms/lsc-jur-102.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LASSEN 2610 Riverside Drive, Susanville, CA 96130

PUBLIC TRANSIT REIMBURSEMENT REQUEST

Name: _____________________________________________ Juror Badge #: _________________________ [Required] [Required]

Address: ____________________________________________________________________________________ [Required] Street City State Zip

Phone Number: ( __ ) __ - __ Email Address: __________________________________ [Required]

TOTAL COST OF ROUND-TRIP
DATE PUBLIC TRANSIT PROVIDER
TRANSIT TRANSPORTATION

CLAIM TOTAL: $

Purpose of Trip and Remarks: ___________________________________________________________________

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I HEREBY CERTIFY that the above statement is a true and correct statement of the public transit expense incurred

by me while traveling for jury duty in and for the Lassen County Superior Court.

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Claimant’s Signature Printed Name Date

Signature, Printed Name, and Date are required for your reimbursement request to be considered.

COURT USE ONLY

Jury Staff Approval ____________________________ ____________________________ ________________ Signature Printed Name Date

Finance Staff _______________ _______ __________________________ __________________________ Claim Processed Date $ Amount Signature Printed Name

Form Adopted for Mandatory Use PUBLIC TRANSIT REIMBURSEMENT REQUEST CCP § 215(d) Lassen Superior Court LSC-JUR-102 [New January 1, 2023] www.LassenCourt.ca.gov