May 17, 2018
Page 1 of 2
ALL REQUESTS FOR REIMBURSEMENT MUST BE SUBMITTED TO THE ADMINISTRATIVE OFFICE OF THE
COURTS NO LATER THAN 60 DAYS AFTER THE LAST DAY OF JURY SERVICE.
ARIZONA LENGTHY TRIAL FUND REIMBURSEMENT REQUEST FORM
1. Person preparing this report: ___________________________________________________________
Name Title
2. County: __________________________________
3. Send payment to: ___________________________________________________________________
Street/P.O. Box City Zip
4. Case No. ___________________________________________________________
5. Dates covered by this request: Start date: __________________ End date: _________________
6. Number of jury service days to date ______________
7. Total number of jurors empanelled for this case _________________________
8. Number of jurors who sought payment from the Arizona Lengthy Trial Fund _______________
□ Please check here if this is a supplemental request.
The date of the original request was _________________.
9. Number of claims denied __________________
10. Total of Arizona Lengthy Trial Fund payments to jurors covered by this request (from Worksheet
below) $ _______________________________.
11. In addition to the payments made to jurors specified above, I hereby request reimbursement for
the following administrative costs permitted by ARS § 21-222(B). I understand that interim payments
made to jurors cannot be the subject of an administrative fee reimbursement request. Number of original
claims filed by jurors (from item 8) _______ x $30 = $ ________________________.
12. TOTAL REIMBURSEMENT REQUESTED: (item 10 plus item 11): $________________________
___________________________________________________ _______________________________
Signature of Jury Commissioner Date
Please submit this request for reimbursement to:
Court Programs Unit
Administrative Office of the Courts
1501 W. Washington, Suite 410
ltfclaims@courts.az.gov
Phoenix, AZ 85007
Phone (602) 452-3364
Fax (602) 452-3659
PLEASE COMPLETE THE WORKSHEET ON PAGE 2
