REQUEST FOR RESTITUTION

Today's Date:

First name

Last name

Country/Region

Address

City

Zip / Postal code

Phone

DA #:

Court #:

Incident Date:

Defendant:

Our records indicated that you might have incurred a loss because of a criminal act committed by the above-named defendant. You have the right to restiution for any financial losses. If the defendant is found responsible and convicted, the judge can order that person to pay you back for any monetary losses or costs from the crime. Please complete this form listing property taken or damaged, lost wages cuased by crime, and/or medical expenses. Return form with documentation of bills, receipts, or if damage has not yet been repaired two written estimates. List only property you believe has not been recovered. Do not list property being temporarily held as evidence by police.

NOTE: all losses requesting restitution must be accompanied by written documentation to substantiate a loss. Items submitted without documentaitno cannot be considered.

Single choice

List of losses or injuries (include dollar amount):

Enter Amount:

Insurance Claim Filed:

Multi choice

Yes

Claim #:

Victims of Crime program claim filed:

Multi choice

Yes

Claim #:

I declare, under penalty of perjury, the foregoing is true and correct.