CLAIM FOR REFUND

							                                  CLAIM FOR REFUND
                    (Must Be Postmarked No Later Than January 21, 2005)
Claimant makes this claim for refund of money paid to the City and County of San Francisco.

1.    Name of Claimant(s):______________________________ AND ____________________________________

2.    Address: _________________________________________________________________________________

3.    I/We paid the following marriage-related fees to the City and County of San Francisco:

      a)    ( ) Marriage License Fee ($82) ........................... Date Paid ____________ Amount: $__________

      b) ( ) Ceremony Fee ($62) ...................................... Date Paid ____________ Amount: $__________

      c)    ( ) Certified copy of marriage license fee ($13) .. Date Paid ____________ Amount: $__________

      d) ( ) Other (please describe): _____________________________________ Amount: $__________

      Total Paid (copies of receipt, check or other verification of payment must be
      provided; otherwise, only $82 marriage license fee will be reimbursed): ........................... $__________

4.    Make check payable to*
      (please mark N/A if refund will be donated): _____________________________________________________

           *Note: Refunds will be made payable to both parties. In order to request for the refund
           to go to only one of the applicants, this request form must be signed by both parties below.

5.    Special Instructions: Please note any special circumstances (e.g., address change, etc.) regarding this claim for
      refund request:

      __________________________________________________________________________________________


I/WE DECLARE (OR AFFIRM) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND
CORRECT:

(Signed): _________________________________                            Printed Name: _______________________________

(Signed)*: ________________________________                            Printed Name: _______________________________

              (* 2nd signature required only if refund is to be made payable to only one of the applicants)


EXECUTED THIS ________ DAY OF __________________, 2004 AT __________________________________
                  (day)               (month)                      (City and State)
_____________________________________________________________________________________________

This form is NOT to be used for refund of property taxes, real estate taxes, improvement taxes, personal property
taxes, or special assessment district taxes.

      Please return completed and signed form in the self-addressed envelope.
---------------------------------------------Section below is for Office use only ---------------------------------------------------

To:         County Clerk’s Office, Room 168, City Hall, San Francisco, California 94102-4678
            I certify the claim above made is legally allowable and recommend a refund of $__________

                                                                                  (Signed): ___________________________
                                                                                                 (Department Head)

                                                                                  (Department): _______________________

                                                                                  (Date): _____________________________