Case Information:
I. Property Damage/Loss
Complete only the sections that apply to your case. If there is no restitution due please skip to part VII.
* If you have additional property damage/losses or need more form fields, please use our additional losses form and then continue.
II. Medical Expenses
Include the cost of prescription drugs, ambulance fees, hospital and laboratory bills, and doctor bills. Please attach all available bills to this form and list the service provider's name(s) below. Some individuals may need more than 30 days to receive bills or complete affadavit.
III. Lost Wages
IV. Other Expenses/Comments
List additional expenses or losses that you have incurred as a result of the criminal act. If an individual, credit card company, bank or some other agency has reimbursed you for all or part of your losses, please provide their name, address and telephone number in the comments
section below.
V. Expenses or Losses Recovered
VI. Restitution
VII. No Restitution
If restitution is due to you, please disregard this section and continue the form.
Affidavit
I do hereby certify that the above answers are true and accurate. I understand that a false statement of answer to any questions in this affidavit will subject me to penalties for perjury.
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