5-1 chapter 5 illustrated forms city and town form no. form page

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CHAPTER 5

ILLUSTRATED FORMS

City and Town Form No.

Form Page

213CT (Rev. 2005) City/Town Court Cash Book 5-3, 5-5213A (1992) City/Town Court Detailed Ledger of Local User Fees 5-7214CT (Rev. 2005) City/Town Court Receipt 5-9215CT (1987) City/Town Court Check 5-11217CT (Rev. 2005) Report to County Auditor of Fines and

Fees Collected in City/Town Courts 5-13218CT (Rev. 2005) City/Town Court Transmittal Report to Fiscal Officer 5-15219CT (Rev. 2005) City/Town Court Daily/Monthly Balance Record 5-17County Form 41 (1990) Fee Book 5-19General Form 102 (1959) Register of Trust Funds 5-21General Form 367 (1984) Clerk's Report to Auditor of Additional Judgments

for Excise Tax 5-23

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CITY/TOWN COURT CASH BOOKPrescribed by State Board of Accounts

RECEIPTSReceipt Clerk's Fiscal

or Overweight Document Late Credit Card Probation Probation OfficersDate Check Fee Book From Whom Received or Total Cash Bond Infraction Vehicle City/Town Document Facsimile Storage Payment Service Probation Administrative Administrative Probation

Mo. Day Number No. Page Case Number to Whom Paid Received State County City/Town State Fines Forfeitures Judgments Fines Fines Fees Fees Fees Fees Fees User Fees Fees Fees Fees

AMOUNT BROUGHT FORWARD

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ChildRestraint

Court Costs SystemFines

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CITY/TOWN FORM 213CT (REV. 2005)

CITY/TOWN COURT OFCITY/TOWN COURT OF __________________

DISBURSEMENTSHighway Automated Judicial

Safe Worksite Domestic Record Insurance Marijuana Bail Bond Special DeathLocal State User Fees Schools Zone Violence Keeping Administration Adjustment Fees - Fees - Administration Processing Service Eradication Cash Administrative Benefit Other Trust Total Fees Paid Fees Paid Fees Paid Cash Other Trust

User Fees Due State Due County Fees Fees Fees Fees Fees Fees State Share City/Town Fees Fees Fees Fees Jury Fees Bonds Fees Fees Fees Funds Disbursements to State to City/Town to County Bonds Fees Funds

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Civil Action DNA SamplePublic

CourtJudicial SalaryJudicial SalaryDefense

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Form Prescribed by State Board of Accounts City/Town Form 213A (1992)

CITY/TOWN COURT OF _____________________________DETAILED LEDGER OF LOCAL USER FEES

Pretrial Alcohol andDate Receipt Fee Book Total Cash Diversion Drug Services Law Enforcement Continuing Education Deferral

Mo. Day Number No. Page Card Number From Whom Received Received Program Program Program

Amount Brought Forward

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TOTALS:

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Form Prescribed by State Board of Accounts Form No. 214CT (Rev. 2005)

CITY/TOWN COURT RECEIPT - COURTCITY/TOWN COURT RECEIPT - _____________________________ COURT

Date Kind Number Page Cash Check M.O. E.F.T. CC-BC Other Case NumberRECORD PAYMENT TYPE AND AMOUNT

$From Whom Received On What Account Total ReceivedFrom Whom Received On What Account Total Received

Court Costs: State User Fees: State Share Alcohol and Drug Countermeasures County Share Drug Abuse, Prosecution: City/Town Share Interdiction and CorrectionsState Fines Safe Schools FeesBond Forfeitures Highway Worksite Zone FeesBond Forfeitures Highway Worksite Zone FeesInfraction Judgments Domestic Violence FeesChild Restraint System Fines Automated Record Keeping FeesOverweight Vehicle Fines Public Defense Administration FeesCity/Town Fines Judicial Insurance Adjustment FeesDocument Fees Judicial Salaries Fees - State ShareFacsimile Fees Judicial Salaries Fees - City/Town ShareDocument Storage Fees Court Administration FeesgLate Payment Fees DNA Sample Processing FeesCredit Card Service Fees Civil Action Service FeesProbation User Fees Cash BondsProbation Administrative Fees Bail Bond Administrative FeesClerk's Probation Administrative Fees Marijuana Eradication FeesFiscal Officer's Probation Administrative Fees Jury FeesLocal User Fees: Special Death Benefit Fees Pretrial Diversion Program Other Fees Alcohol and Drug Service Program Trust Funds Law Enforcement Continuing Education Deferral Program Drug Court TOTAL

(Judge)(Clerk) City/Town Court

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Form Prescribed by State Board of Accounts City and Town Form No 215 (1987)Form Prescribed by State Board of Accounts City and Town Form No. 215 (1987)

CITY/TOWN COURT

____________ , _________ No.

PAY TO THE ORDER OF $

DOLLARS

FOR

DOCKET NO. PAGE CAUSE NO.

(Judge) (Clerk) City/Town Court

Form Prescribed by State Board of Accounts City and Town Form No. 215 (1987)

CITY/TOWN COURT

No____________ , _________ No.


DOLLARS

FOR

DOCKET NO PAGE CAUSE NODOCKET NO. PAGE CAUSE NO.


Form Prescribed by State Board of Accounts City and Town Form No. 215 (1987)

CITY/TOWN COURT

____________ , _________ No.


DOLLARSDOLLARS

FOR

DOCKET NO. PAGE CAUSE NO.


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PRESCRIBED BY STATE BOARD OF ACCOUNTS CITY AND TOWN FORM 217CT (REV 2005)PRESCRIBED BY STATE BOARD OF ACCOUNTS CITY AND TOWN FORM 217CT (REV. 2005)

REPORT TO COUNTY AUDITOR OF FINES AND FEESCOLLECTED IN CITY/TOWN COURT

To the Auditor of _______________________________________________, County, Indiana

I, ______________________________________, (Judge) (Clerk) of ___________________City/Town Court, hereby certify that I have collected the following amounts of fines and forfeiturespayable to the county:

For the month ending _______________________________________, ________________

Collections Prior Year to DateItemization This Period Collections Collections

State FinesBond ForfeituresInfraction JudgmentsChild Restraint System FinesChild Restraint System FinesOverweight Vehicle FinesState User Fees (75%) - County Drug Free Community FundMarijuana Eradication FeesJury FeesTOTAL AMOUNT COLLECTED

Dated __________________________, ____

______________________________________(Judge) (Clerk) ____________ City/Town Court

NOTE - Mail To:

______________________________ County Auditor

__________________________________________

__________________________________________

(Make check payable to _________________ County Treasurer)

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PRESCRIBED BY STATE BOARD OF ACCOUNTS CITY AND TOWN FORM 218CT (Rev. 2005)

_________________________ CITY/TOWN COURTTRANSMITTAL REPORT TO FISCAL OFFICER

Date: __________________________________

TO: Fiscal Officer of ______________________________________

I hereby certify that the following fines, costs and fees represent the total collections due on this date.y y g , p

Judge/Clerk of Court

Collections Prior Year to DateItems This Period Collections Collections

D Fi l OffiDue Fiscal Officer

Court Costs: County................................................................... $ $ $ City/Town..............................................................City/Town Fines.......................................................Document Fees........................................................Bail Bond Administrative Fees.................................Facsimile FeesFacsimile Fees.........................................................Document Storage Fees..........................................Late Payment Fees..................................................Credit Card Service Fees........................................Probation User Fees................................................Probation Administrative Fees.................................Clerk's Probation Administrative Fees.....................Fiscal Officer's Probation Administrative Fees........ Judicial Salaries Fees - City/Town ShareCivil Action Service FeesUser Fees: Pretrial Diversion Program.................................... Alcohol and Drug Services Program..................... Law Enforcement Continuing Education.............. Deferral Program.................................................. Drug Court………….............................................. Other Items:

TOTALS $ $ $

(Judge) (Clerk) of ________________ City/Town Court

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5 - 17CITY/TOWN COURT DAILY/MONTHLY BALANCE RECORD

Date of Balance ______________________, 20___ Daily ________ Monthly ________

Form Prescribed by State Board of Accounts City Town Form No. 219CT (Rev. 2005)

Beginning Receipts Disbursements EndingBalance During Period for Period Balance

Payable to State: Court Costs - 55% State User Fees - 25% Safe Schools Fees Highway Worksite Zone Fees Domestic Violence Fees Automated Record Keeping Fees Public Defense Administration Fees Judicial Insurance Adjustment Fees Judicial Salaries Fees - State Share

Court Administration Fees DNA Sample Processing Fees Special Death Benefit FeesPayable to Fiscal Officer: Court Costs: County - 20% City/Town - 25% City/Town Fines Document Fees Facsimile Fees Document Storage Fees Late Payment Fees Credit Card Service Fees Probation User Fees Probation Administrative Fees Clerk's Probation Administrative Fees Fiscal Officer's Probation Administrative Fees

Judicial Salaries Fees - City/Town Share Judicial Salaries Fees - City/Town Share Civil Action Service Fees Bail Bond Administrative Fees User Fees: Pretrial Diversion Program Alcohol and Drug Services Program Law Enforcement Continuing Education Deferral Program Drug CourtPayable to County: State Fines Bond Forfeiutres Infraction Judgments Child Restraint System Fines Overweight Vehicle Fines State User Fees - 75% Marijuana Eradication Fees Jury Fees

Cash BondsOther FeesTrust Funds

Totals

CASH RECONCILEMENT___________________, 20__

Depository DepositoryBalance at Balance atBeginning Close

Name of Depository of Period Deposits Checks Issued of Period

Bank Bank

InvestmentsTotalsAdd Cash on Hand at End of Period x x x x x x x x x x x x x x x x x x x x xPlus Cash Short or Minus Cash Long x x x x x x x x x x x x x x x x x x x x xTotal Cash Balance x x x x x x x x x x x x x x x x x x x x x

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Form Prescribed by State Board of Accounts County Form No. 41 (1990)

FEE BOOK1

Date Filed ____________ Case No. _______________________Additional Information or Receipt (Plaintiffs) (Defendants) __________________________________________________________ vs __________________________User Fees ________________________C t C t R i t N Mi FCourt Costs ________________ Receipts No. ______________Misc. Fees _______________________Amount of Judgment ____________________________________________________________________Date of Judgment __________ JD ___________ Pg. No. _____ __________________________________Other Information _______________________________________________________________________

Date Filed Case No Additional Information or ReceiptDate Filed ____________ Case No. _______________________Additional Information or Receipt (Plaintiffs) (Defendants) __________________________________________________________ vs __________________________User Fees ________________________Court Costs ________________ Receipts No. ______________Misc. Fees _______________________Amount of Judgment ____________________________________________________________________Date of Judgment __________ JD ___________ Pg. No. _____ __________________________________Other Information _______________________________________________________________________

Date Filed ____________ Case No. _______________________Additional Information or Receipt (Plaintiffs) (Defendants) __________________________________________________________ vs __________________________User Fees ________________________Court Costs ________________ Receipts No. ______________Misc. Fees _______________________Amount of Judgment ____________________________________________________________________D t f J d t JD P NDate of Judgment __________ JD ___________ Pg. No. _____ __________________________________Other Information _______________________________________________________________________

Date Filed ____________ Case No. _______________________Additional Information or Receipt (Plaintiffs) (Defendants) __________________________________

vs User Fees________________________ vs __________________________User Fees ________________________Court Costs ________________ Receipts No. ______________Misc. Fees _______________________Amount of Judgment ____________________________________________________________________Date of Judgment __________ JD ___________ Pg. No. _____ __________________________________Other Information _______________________________________________________________________

Date Filed ____________ Case No. _______________________Additional Information or Receipt (Plaintiffs) (Defendants) __________________________________________________________ vs __________________________User Fees ________________________Court Costs ________________ Receipts No. ______________Misc. Fees _______________________Amount of Judgment ____________________________________________________________________Date of Judgment __________ JD ___________ Pg. No. _____ __________________________________Other Information _______________________________________________________________________

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REGISTER OF TRUST FUNDSREGISTER OF TRUST FUNDSForm Prescribed by State Board of Accounts General Form No. 102 (1959)

DATE RECEIVED RECEIPT CAUSE RECORD AMOUNT DATE DISBURSED CHECK AMOUNTMONTH DAY YEAR NUMBER FOR WHOM RECEIVED NUMBER DOCKET PAGE RECEIVED MONTH DAY YEAR NUMBER DISBURSED MEMORANDA

123456789

10101112131415161717181920212223242425262728293031313233343536373838394041

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PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 367 (1984)

CLERK'S REPORT TO AUDITOROF ADDITIONAL JUDGMENTS FOR EXCISE TAX

TO THE AUDITOR OF ___________________________ COUNTY, INDIANA

COLLECTIONS FOR MONTH _________________________, ____

NO. OF CITATIONS AMOUNT

LAW ENFORCEMENT AGENCY ISSUED COLLECTEDLAW ENFORCEMENT AGENCY ISSUED COLLECTED

STATE POLICE

COUNTY SHERIFF

CITY OF POLICE

CITY OF POLICE

TOWN MARSHAL - TOWN OF

TOTALS $

I SWEAR THAT THE ABOVE IS A TRUE AND CORRECT STATEMENT OF ALL COSTS AND FEES BELONGING TO THE ABOVE AGENCIES AND DEPARTMENTS COLLECTED BY ME FOR THE PERIOD SHOWN.

STATE OF INDIANA __________________________ COUNTY, SS

IC 9-18-2-41 PROVIDES THAT THE CLERK OF THE COURT SHALL ON A CALENDAR YEAR BASIS TRANSFER ADDITIONAL JUDGMENTS COLLECTED UNDER IC 9-18-2-1 TO THE COUNTY AUDITOR WHO SHALL DISTRIBUTE THE FUNDS TO THE LAW ENFORCEMENT AGENCIES RESPONSIBLE FOR ISSUING CITATIONS. THE PERCENTAGE OF FUNDS DISTRIBUTED TO A LAW ENFORCEMENT AGENCY EQUALS THE TOTAL NUMBER OF CITATIONS ISSUED BY THE LAW ENFORCEMENT AGENCY. THE STATE BOARD OF ACCOUNTS RECOMMENDS MONTHLY FILING OF THIS FORM TO ELIMINATE THE NECESSITY OF CARRYING THESE ITEMS IN TRUST.

__________________________ COURT

___________________________________CLERK OF THE COURT

5-1 chapter 5 illustrated forms city and town form no. form page

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