Order For Drug Test Reimbursement {JU 38}

ORDER FOR DRUG TEST REIMBURSEMENT JU-38 Rev. 10/23 County Code _______ Case Number JU _ _ _ _ _ _ _ _ _ _ _ Jurisdiction Year Case# Suffix Mark Appropriate Court: In the Circuit Court of _______________________ County In the District Court of _______________________ County IN THE MATTER OF ___________ (initials only), A CHILD DATE OF TEST _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ AMOUNT _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ TOTAL CLAIM : _______________________ The undersigned declares that the above claim is true and correct, represents the services actually rendered and the amount is due and payable pursuant to Ala. Code 1975 §12-15-215(a)(4). I further declare that the above claim is not a duplication of charges and expenses in any case (companion or otherwise). Said claim should be paid to: Name and address of Payee: (please type or print, including city, state and zip code) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Telephone No.:____________________ Fax No.:____________________ __________________________________________________ Signature ____________________________________________________________ Title Sworn to and subscribed before me this ____________ _____________________________________________ Day of ___________________________, ___________ Notary Public I, the undersigned judge, hereby certify that the foregoing claim has been presented to me, and I have reviewed the same and believe the same to be true, correct and payable pursuant Ala. Code 1975, §12-15-215(a)(4). I am further of the opinion that said claimant is not duplicating charges and expenses in any case (companion or otherwise). Based on the above, I hereby approve the declaration and claim in the amount of $_______________ and order that the State of Alabama reimburse _______________________________________ (payee). Done this _______________ day of _______________________________, ___________. _________________________________________________________________ Judge's Signature THIS FORM MUST CONTAIN ORIGINAL SIGNATURES OF THE CLAIMANT AND THE JUDGE. THIS FORM MUST BE SUBMITTED TO THE TRIAL COURT JUDGE OR PRESIDING JUVENILE JUDGE FOR APPROVAL. AFTER APPROVAL, FILE WITH THE CLERK WHO SHALL SUBMIT THE ORIGINAL DECLARATION TO THE STATE COMPTROLLER. Filed in the Clerk's Office at _______________________________, Alabama, on __________________________. date MAIL TO: State Comptroller, P.O. BOX 302602, Montgomery, Alabama 36130-2602. Original: Comptroller Copy: Court File www.FormsWorkFlow.com