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RESTITUTION REQUEST FORM: IF YOU ARE A VICTIM OF A CRIME PLEASE FILL OUT THE FORM COMPLETELY.
Victim Full Name:
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?
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.
Copyright © 2016
Crawford County Attorney
Michael Gayoso, Jr.