Reimbursement Request

APPLICATION TO RECEIVE REIMBURSEMENT EXPENSES PAID TO THE CIRCUIT COURT CLERK BY THE NON-PREVAILING PARTY DATE: ________________________________ CASE ID# __________________________ STYLE OF CASE __________________________________________________ VS. __________________________________________________ ATTORNEY NAME _______________________________________________ TELEPHONE # _______________________________________________ ADDRESS _______________________________________________ ______________________________________________ ______________________________________________ Note: The Circuit Court Clerk will make checks payable to the party who originally paid the filing fees. Your application will be accepted after ten (10) banking days have expired since payment was received from the Cost Bill Debtor. I have received the reimbursement check for which I made application above. ___________________________________ Signature Check # _________________________________ ________________________ Date Check amount $ _______________ American LegalNet, Inc. www.FormsWorkFlow.com