Sedgwick County...working for you

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


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

*First:     

Middle:   

*Last:     

*Case No:     


 

COMPLETE VICTIM INFORMATION WHERE APPLICABLE

Victim Name: 

First:   

Middle:   

Last:   

DOB:

Sex:

Race:

Business Name:  

Attention:  

Address:  

City:  

State:   

Zip Code:   

Home Phone:  

Work Phone:  

Other Phone:  

Fax:   


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

First:   

Middle:   

Last:   

Relationship:   

DOB:

Sex:

Race:

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.)?

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