IN THE FOURTH JUDICIAL DISTRICT COURT
    STATE OF UTAH 

COURT LOCATION ___________________

                                                             ,
                                                         Plaintiff
                     vs.
   
                                                             ,
                                                         Defendant

                  Bail Refund Request

Case #                                                       

Judge                                                         

Request for Bail Refund

Section #1
N To be completed by the person who posted bail:

By signing below I state that I am the person who posted $                            bail for the above named
case/defendant and therefore am entitled to a refund of that bail.

Date:                                                                             **If payor of the bail is requesting it to be

Signed:                                                                          released to another party, please indicate:

Print Name:                                                                   Name:                                                               

Address:                                                                       Address:                                                            

                                                                                                                                                                

Phone:                                                                          Signed:                                                              

“ Please apply $                            to case #                                                      Initials:                    
“ Please refund $                           and call                                       when check is ready,  OR 
“ Please mail refund to above address.

***PLEASE ALLOW 30 DAYS FOR REFUND TO BE PROCESSED***

Section #2
N To be completed by the Court:
“ {Initial} Clerk verified payor on bail commissioner release form is the same person as in section 1:

Name of Payor:                                                    

Date:                                                                               Date:                                                               

Approved:                                                                     Denied:                                                           

            District Court Judge                                                  District Court Judge

Section #3
N To be completed by Accounting:

Date:                           $                           Applied to case by    “ Transfer       “ Check #                        

Date:                           $                           Refunded to                                                Check #