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: (required)

*First: (required)

Middle:

*Last: (required)

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: Please enter a valid date

Sex:

Address:

City:

State:

Zip Code:

Home Phone: Please enter a valid phone number

Work Phone: Please enter a valid phone number

Other Phone: Please enter a valid phone number

Fax: Please enter a valid phone number

Email: Please enter a valid email

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

First:

Middle:

Last:

Relationship:

DOB(mm/dd/yyyy): Please enter a valid date

Sex:

Address:

City:

State:

Zip Code:

Home Phone: Please enter a valid phone number

Work Phone: Please enter a valid phone number

Other Phone: Please enter a valid phone number

Fax: Please enter a valid phone number

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

Yes

IF YES complete the following:

Insurance company:

Agent:

Address:

Phone: Please enter a valid phone number

City:

State:

Zip Code:

Policy Number:

Insurance Claim Number:

Deductible: $ Please enter a dollar amount

If Known, Amount insurance will pay: $ Please enter a dollar amount

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.