Request For Restitution - Property Loss

OFFICE OF THE DISTRICT ATTORNEY - 18TH JUDICIAL DISTRICT


REQUEST FOR RESTITUTION - PROPERTY LOSS

 

Note the * indicates a required field

Defendent/Offenders Name:
*First:
Middle:

* Last:

 * Case No. Please enter only ONE Case Number per form.

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:

Business Name: 

Attention: 

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: 

 
WAS A CLAIM FILED WITH ANY PROPERTY INSURANCE COMPANY? Yes No N/A  
If Yes, Please complete the following:

Insurance Company: 
Agent: 
 

Address:   Phone: 

City:  State:  Zip Code:   

Policy No:   Claim No: 

Deductible $  If Known, Amount insurance will pay $ 

 
WAS A CLAIM FILED WITH AN AUTOMOBILE INSURANCE COMPANY?
Yes No  Liability Only  
If Yes, Please complete the following:

Insurance Company: 
Agent: 
 

Address:   Phone:     

City:  State:   Zip Code:   

Policy No:    Claim No:   

Deductible $ If Known, Amount insurance will pay $

 
*
Your Name:

Entering your name in the above field and clicking the submit button below constitutes your electronic signature of this form.