OFFICE OF THE DISTRICT ATTORNEY - 18TH JUDICIAL DISTRICT
REQUEST FOR RESTITUTION - PROPERTY AND /OR MEDICAL LOSS

Note: the * indicates a required field
Defendant/Offender's Name:

*Case No:

*First:

Middle:

*Last:

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 or Business Name:

First: Business Name:

Middle: Attention:

Last:

DOB:

Sex:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Other Phone:

Fax:

Email:

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

First:

Middle:

Last:

Relationship:

DOB(mm/dd/yyyy):

Sex:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Other Phone:

Fax:

Was a claim filed with any insurance company or government public assistance program (DCF- medical card, Medicaid, Medicare etc.)? YesNo

IF YES complete the following:

Insurance company:

Agent:

Address:

Phone:

City:

State:

Zip Code:

Policy Number:

Insurance Claim Number:

Deductible: $

If Known, Amount insurance will pay: $

If the victim suffered personal injury or death, please complete the "Crime Victim Compensation" application form accessed at: http://ag.ks.gov/docs/default-source/forms/application-for-crime-victim-compensation.pdf, and mail it to the Topeka address on that form for processing.