Refund Application

FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA OFFICE OF JUDICIAL RECORDS - CIVIL REFUND APPLICATION Return to: Room 296, City Hall Philadelphia, PA 19107 Or Fax to: 215-686-8397 NAME AND ADDRESS OF PAYEE: APPROVED BY: Office of Judicial Records Finance Office Amount of Refund Request: $ CASE CAPTION: Court Term & Number: vs. STATEMENT OF FACTS: Note: Please attach your original cash register receipt or proof of payment, along with a copy of the civil docket report. PAYEE'S SIGNATURE Date: 10-285 (Rev. 8/2014) American LegalNet, Inc. www.FormsWorkFlow.com