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

Preferred Contact Method


Defendant(s) Court Case Number:

Please check at least ONE box:

Please complete section 1.
Please complete sections 1, 2, and 3 as appropriate.

Do you expect any future additional costs?

      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.


2. Property Damage/Loss

Please send in copies of supporting documentation via email to

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

3. Medical Bills

Please send in copies of supporting documentation via email to

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

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