5. What specific concerns do you have about the defendant (Consider things such as: fear that the
defendant will try to contact or harass you; fear that the Defendant possesses firearms that they may
attempt to use against you, and alcohol/drug abuse by the defendant)?
6. Financial loss that was due to the charged criminal offense (Copies of all receipts or estimates must
be attached to this form. Failure to provide proper documentation may result in failure to have
restitution ordered. Requests for restitution do not ensure that financial compensation is warrante
d.
You may be asked to provide additional proof of loss and a restitution hearing may be ordered):
PROPERTY LOSS
DESCRIPTION OF LOSS:
RECOVERED / REPAIRED:
PURCHASE PRICE OR CURRENT VALUE: ________________ DATE __________
REPAIR COST / ESTIMATE DATE __________
LOSS COVERED BY INSURANCE? Yes _____ No _____ DEDUCTIBLE (IF ANY)? __________
INSURANCE CO. (name, address, number): ______________________________________________
POLICY NUMBER: _________________________
MEDICAL EXPENSES
DESCRIPTION OF SERVICES:
DOCTOR/HOSPITAL (NAME & NUMBER):
TOTAL EXPENSE: ________________________ DEDUCTIBLE:________________________
AMOUNT PAID BY INSURANCE: _________________
INSURANCE CO. (name, address, number): ______________________________________________
POLICY NUMBER: _________________________
LOSS OF WAGES DUE TO INJURIES OR MEDICAL TREATMENT/COUNSELING:
HOURS/DAYS MISSED: HOURLY WAGE/SALARY:
** IF LOST WAGES ARE REQUESTED, YOU MUST PROVIDE A COPY OF YOUR TIMESLIP
AND A LETTER FROM YOUR EMPLOYER VERIFYING YOUR WAGES AND TIME MISSED.
SIGNATURE DATE
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