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CAND Pay.gov Application for Refund (rev. 5/17) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA APPLICATION FOR REFUND (USDC-CAND PAY.GOV) PAY.GOV TRANSACTION DETAILS IMPORTANT: Complete all required fields (shown in red*); otherwise, your request may be denied and require resubmission. In fields 3-7, enter the information for the incorrect transaction (the one for which you are requesting a refund), not the correct transaction that appears on the docket. This information can be found in the Pay.gov screen receipt or confirmation email. 1. Your Name:* 2. Your Email Address: * 3. Pay.gov Tracking ID Number:* 4. Agency Tracking ID Number:* 09715. Transaction Date:* 6. Transaction Time:* 7. Transaction Amount (Amount to be refunded):* 8. Your Phone Number: 9. Full Case Number (if applicable): Attorney Admission Civil Case Filing FTR Audio Recording Notice of Appeal Pro Hac Vice Writ of Habeas Corpus 10. Fee Type:* 11. Reason for Refund Request:* Explain in detail what happened to cause duplicate charges or no fee required. For a duplicate charge, provide the correct Pay.gov and Agency Tracking numbers in this field. If you paid a filing fee in an abandoned case number, note that case number here (but e-file the refund request in the open case). Efile this form using OTHER FILINGS OTHER DOCUMENTS APPLICATION FOR REFUND. View detailed instructions at: cand.uscourts.gov/ecf/payments. For assistance, contact the ECF Help Desk at 1-866-638-7829 or firstname.lastname@example.org Monday -Friday 9:00 a.m.-4:00 p.m. FOR U.S. DISTRICT COURT USE ONLY Refund request: Approved Denied Denied Resubmit amended application (see reason for denial) Request approved/denied by: Agency refund tracking ID number: 0971Refund processed by: Approval/denial date: Pay.gov refund tracking ID refunded: Date refund processed: Reason for denial (if applicable): Referred for OSC date (if applicable): American LegalNet, Inc. www.FormsWorkFlow.com