OFFICE OF THE DISTRICT ATTORNEY - 18TH JUDICIAL DISTRICT

REQUEST FOR RESTITUTION - MEDICAL
 

Note the * indicates a required fields
Defendant/Offender's Name:
*
First: 
Middle: 

* Last: 
* Case No:

IF YOU FEEL THAT RESTITUTION IS NOT OWED TO YOU, OR YOU DO NOT WISH TO FILE FOR RESTITUTION NOW OR IN THE FUTURE, PLEASE CHECK THIS BOX AND ENTER YOUR NAME AT THE BOTTOM OF THIS PAGE.


COMPLETE VICTIM INFORMATION WHERE APPLICABLE
 

Victim Name:
 

First: 

Middle: 

Last: 
DOB (example 01/01/2001):    Sex:
Race:
Address:   SSN:
City:    State: Zip:
Note: Do not enter dashes or parenthesis in phone numbers.  Example 0001112222
Home Phone: 
Work:  Other:  Fax: 

IF VICTIM IS A MINOR,
LIST NAME OF PARENT OR GUARDIAN:

 
First:
Middle:

Last: 
Relationship:    SSN: 
DOB (example 01/01/2001):   Sex: 
Race:
Address: 
City:    State:  Zip: 
Note: Do not enter dashes or parenthesis in phone numbers.  Example 0001112222
Home Phone: 
Work:  Other:  Fax: 

MEDICAL INSURANCE INFORMATION
 
Include Personal, Work or Government assistance programs
Will a claim be filed with any insurance company or government public assistance program 
(SRS- medical card, medicaid, medicare etc.)? Yes No
IF YES complete the following:
Insurance company or government program:
Address:  Phone:  
City: State:   Zip: 
Policy No:     Claim No:
Deductible $   If Known, Amount insurance will pay $

PERSONAL INJURY OR DEATH

 
If the victim suffered personal injury or death, Please complete the "Crime Victim Compensation" application form enclosed in the packet you received from our office, and mail it to Topeka address on that form for processing.
* Your Name:  
  Email Address:

Entering your name in the above field and clicking the submit button below constitutes your electronic signature of this form. Please enter an email address to assist us when there are any technical problems.