Restitution Request

If this form is not completed and returned, you may not receive restitution in this matter.

At the time of sentencing, a defendant can be ordered to pay restitution to a victim, which is any out-of-pocket expenses and/or future expenses a victim may have regarding the criminal case. This process is a long process that can take months and/or years to receive.

Please take a moment to fill out this form so the Judge may order the correct amount of restitution in your case. Where possible, please provide receipts or estimates, and keep a copy for your records.

Core Details

Victim

Phone

Preferred Contact Method

Email Phone

Defendant(s)	Court Case Number:

Please check at least ONE box:

I am not requesting restitution.

My insurance company has covered the entire loss, except that I had to pay my insurance deductible which is . Please complete section 1.

I have losses that were not or only partially covered by insurance. The total amount of my out-of-pocket expenses (including any deductible that I've paid) is as described below. Please complete sections 1, 2, and 3 as appropriate.

Do you expect any future additional costs?

Yes No Please attach explanation/estimate of future costs.

1. Insurance Information

Please list each insurance company that you are aware is involved in this case. Under the "cost to you" please list any insurance related out-of-pocket expenses that you have actually had to pay (a deductible or co-pay). You will be able to itemize uncovered losses below.

Claim Number

Company Name

Adjustor Name

Phone Number

This is: My Insurance Defendant's Insurance

Cost to Victim $

Amount Paid by Insurance $

2. Property Damage/Loss

Please send in copies of supporting documentation via email to advocates@cachecounty.gov.

Item/Brief Description of Damage	Type of Expense	Cost to You

3. Medical Bills

Please send in copies of supporting documentation via email to advocates@cachecounty.gov.

Treatment Date(s)	Hospital/Provider & Desc. of Expense	Cost to You

Due to the injuries sustained in this incident, I could not work and lost wages that were not covered by sick time or worker's compensation. Please specify amount and attach documentation.

Lost Wages

To the best of my knowledge, the above facts are true and accurate.

Signature: