Michael Gayoso, Jr. - Victim Restitution Request

Michael Gayoso, Jr. - Crawford County Attorney


RESTITUTION REQUEST FORM: IF YOU ARE A VICTIM OF A CRIME PLEASE FILL OUT THE FORM COMPLETELY.
__________________________________________________________
Victim Full Name:
Company Name:
Email:
Home Phone:
Cell Phone:
Address 1:
Address 2:
City:
State:
Zip Code:
Defendant's Name:
Case No.:
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 BELOW. I do not wish to request restitution.
IF YOU WISH TO MAKE A CLAIM FOR RESTITUTION--List, in detail, description and amount of restitution
WAS A CLAIM FILED WITH ANY PROPERTY INSURANCE COMPANY? Yes No Not applicable
If Yes, Please Provide Name of Insurance Company, Agent, Phone No., Claim No., Policy No., and Amount of Deductible
Your Name: Entering your name in the below field and clicking the submit button below constitutes your electronic signature of this form.
Please enter date of you submitting this restitution request to our office.

ADDITIONAL INFORMATION MAY BE REQUIRED AT A LATER TIME---IF THE VICTIM IS A MINOR, LIST NAME OF PARENT OR GUARDIAN.

***SUBMISSION OF THIS REQUEST FOR RESTITUTION IS INTENDED SOLELY FOR VICTIMS OF CRIME. IF YOU ARE NOT THE VICTIM OF A CRIME AND SUBMIT THIS FORM, YOU MAY BE CHARGED WITH A FELONY***

"Making false information is making, generating, distributing or drawing, or causing to be made, generated, distributed or drawn, any written instrument, electronic data or entry in a book of account with knowledge that such information falsely states or represents some material matter or is not what it purports to be, and with intent to defraud, obstruct the detection of a theft or felony offense or induce official action. Making false information is a severity level 8, nonperson felony."