Victim Restitution Form VICTIM RESTITUTION FORMDate Sent MM slash DD slash YYYY Victim's NameCommonwealth VS.Docket CR #Assistant District AttorneyRestitution is ordered by the Judge as a part of a defendant’s sentence to reimburse victims for their direct losses as a result of the crime. Restitution can include property losses and damage, medical bills, counseling bills, and funeral expenses. Restitution can be ordered to be paid directly to you for out of pocket expenses, bills you have already paid or may still owe, and insurance deductibles. Payment of restitution can also be ordered to your insurance companies or other benefit plans, which has paid your bills or reimbursed you for your losses. Please include copies of receipts and bills for all losses. Restitution cannot be claimed for lost wages, mileage to court hearings, or pain and suffering. If you do not return this form to our office within ten (10) days the court will assume you had no financial losses to claim. Please see attached Restitution Form and describe any property stolen, lost, destroyed or damaged as a result of this crime and the value of that property. If there is no restitution owed in this case, check this box: 1. Itemized List of Property LossesPropertyValue2. Medical Treatment Required for Injuries and Counseling Costs (please include copies of bills). Use additional sheets, if necessary.DatesHospital/Doctor/Prescriptions/CounselorAmount3. Did any Insurance Companies pay for losses? Yes No If yes, please contact your insurance company and request that they submit a restitution request to our office. Without this information restitution will not be ordered for the insurance company. Please include the claim #.a. Insurance Type: Auto Medical Homeowner Defendant’s Work Benefit Other Insurance Company and Agent Name:AddressClaim #Policy #Your deductibleAmount Insurance paidb. Insurance Type: Auto Medical Homeowner Defendant’s Work Benefit Other Insurance Company and Agent Name:AddressClaim #Policy #Your deductibleAmount Insurance paid4. Amount of loss due to Forgery, Bad Checks, Credit Card/MAC Card misuse or other financial crimes. Type of LossAmount of LossIf a bank or a credit card company reimbursed your losses, please provide this information.NameAmount PaidAddressTelephone #Account #Total Out Of Pocket Expenses For Items 1-45. Have you applied for Crime Victims Compensation? Yes No Amount PaidClaim #I hereby swear that the information I have provided is true and accurate to the best of my knowledge. I give permission for any entity that may have paid bills related to this case on my behalf to release information concerning those payments to the District Attorney’s Office. Date MM slash DD slash YYYY
