There has been no previous order to refund or forfeit the deposit and it is eligible for refund as provided under Code of Civil Procedure § 631.3. Receipt No.: ______________________________ Dated: ______________________. 2. IT IS REQUESTED that the sum of $ ________________________ as deposited above be paid to: Claimant: ____________________________________________________________________________________ Address: _____________________________________________________________________________________ ______________________________________________________________________________________ 3.

I declare under penalty of perjury under the law of the State of California that the forgoing is true and correct. Executed at: __________________________________ _____, California, on ____________________________. > __________________________________________________ CLAIMANT / DECLARANT FOR COURT USE ONLY Jury Fee Deposit – Eligible for Refund. Request is over 20 days from date case settled/dismissed/continued – Not Eligible for Refund. Jury Fee Deposit previously refunded on _______________________ – Not Eligible for Refund.

Other: ___________________________________________________________________________ Verified by: _______________________________________________________ Date: _________________________ Superior Court of California, County of Alameda DECLARATION AND ORDER FOR PAYMENT OF MONEY (Jury Fee Deposit) Superior Court of California, County of Alameda DECLARATION AND ORDER FOR PAYMENT OF MONEY (Jury Fee Deposit) Jury Fee Deposit Form PLANTIFF: DEFENDANT: CASE NUMBER: ORDER FOR PAYMENT OF MONEY The request for refund of the jury fee deposit is GRANTED. DENIED.

Date: _ ________________________________________________________ JUDGE OF THE SUPERIOR COURT