Restitution Claim Form
Step 1 of 4 25% Section 1: Case InformationJuvenile/Defendant's Name(Required) First Last Case Number(Required) Victim's Name(Required) First Last Section 2: Property [If Applicable]Status NONE Property Recovered/No Damage Partially Recovered/Partially Damaged Not Recovered/Fully Damaged Police took Custody Uninsured Property Loss: List UNINSURED property destroyed, damaged or stolen from this incident. We must prove the “fair market value” or “as is” value of each item lost. Replacement value is not the same as fair market value. You should, if possible, document the fair market value of the item(s) that were damaged, destroyed or stolen.PropertyUninsured Property Stolen/DestroyedProperty Fair Market Value Add RemoveA. Total Property ValueInsurance Information: If any damaged/stolen property were/are covered by an insurance provider please fill out the information below:Insurer Name Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Party Insured First Last Agent Contact Phone NumberPropertyClaim #Insured PropertyOut of Pocket/DeductibleAmt Covered by Insurer Add RemoveB. Total Out of Pocket SECTION 3: PHYSICAL INJURY/MEDICAL BILLS [IF APPLICABLE]Describe victim’s physical injuries:Were photos taken of victims injuries? Yes No If so, who has the photos? Did the victim seek medical treatment? Yes No If so, please list the doctor, hospital and treatment provided. Additionally, please forward my office any medical bills or invoices for the medical services.DoctorHospital/FacilityTreatment Add RemoveCosts/Insurance Information: If any of the items listed above were/are covered by an insurance provider please fill out the information below:Insurer Name: Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Party Insured: First Last Agent Contact Phone Number:Medical BillsDoctorOut of Pocket/DeductibleAmount Covered by Insurer Add RemoveC. Total Out of Pocket SECTION 4: COUNSELLING [IF APPLICABLE]Did the crime cause the victim to seek counseling with a physician, psychiatrist, psychologist or some other professional? Yes No If so, please list the professional, their contact information and out of pocket costs. Additionally, please forward my office any bills for the counselling services.CounsellorContact Info Add RemoveInsurance Information: If any of the items listed above were/are covered by an insurance provider please fill out the information below:Insurer Name: Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Party Insured: First Last Agent Contact Phone Number:CounellingCounsellorOut of Pocket/DeductibleAmount Covered by Insurer Add RemoveD. Total Out of PocketSECTION 5: LOSS OF WORK/CHILD CARE EXPENSES [IF APPLICABLE]If the victim missed work or incurred child care expenses as a result of the crime, please provide the following information requested below. Additionally, please forward my office any documentation for the listed items. WorkEmployerTime LostHourly PayTotal Loss of Pay Add RemoveE. Total Pay LossChild CareChild Care HoursChild Care Hourly CostTotal Financial Cost Add RemoveF. Total Child Care Financial Cost SECTION 6: COSTS TO ATTEND COURT HEARINGS AND/OR MEET WITH LAW ENFORCEMENTCourt CostsDate to CourtDistance in MilesCost [$.50/mile] Add RemoveG. Total Mileage CostSECTION 7: OTHER CLAIMS OF RESTITUTIONPlease list any additional out of pocket losses you have experienced that may not be included in this document.SECTION 8: TOTAL RESTITUTION CLAIM – FOREA. Uninsured Property Loss: B. Insured Property Out of Pocket/Deductible Loss: C. Out of Pocket/Deductible Medical Bills D. Out of Pocket/Deductible Counselling E. Loss of work Pay F. Child Care Expenses G. Court/Investigation Costs Additional Claims for Restitution Total Restitution Claim
Prosecuting Attorney
Melissa Goodrich
(231) 627-8450