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Victim’s Information

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Case # (Court and/or Case ID # if known)

DR# (Police report number if known)

Incident Date *

Victim's Name *

First

Last

Contact Information *

Address Line 1

City

State

Zip Code

Phone *

Email

Are you seeking restitution? *

YES
NO

Is this the address you would like the defendant to use for restitution payments? *

YES
NO

Please indicate address where payments should be sent.

Address Line 1

Address Line 2

City

State

Zip Code

Did you experience property loss or damage?

Please Describe – Property Stolen / Damaged (PC 1202.4(f)(3)(A))

Please list any items stolen/damaged along with any comments you have.

Please Upload any Documentation or Receipts

Drag & Drop Files, Choose Files to Upload You can upload up to 30 files.

Estimated Value of Loss

Did you have Medical or Mental-Health Counseling Expenses?

Please Describe – Medical Expenses / Mental-Health Counseling (PC 1202.4(f)(3)(B))

Please Upload any Documentation or Receipts

Drag & Drop Files, Choose Files to Upload You can upload up to 30 files.

Estimated Value of Loss

Did you have any lost wages?

Lost Wages / Profits (PC 1202.4(f)(3)(D), (E))

Incurred by Victim Due to Injury
Incurred While Caring for Child or Family Member
Incurred in Time Spent as Witness / Assisting Prosecution / Coming to Court

Please Describe – Lost Wages

Please Upload any Documentation or Receipts (copy)

Drag & Drop Files, Choose Files to Upload You can upload up to 30 files.

Estimated Value of Loss

Did you have any additional expenses?

Additional Expenses (PC 1202.4(f)(3)(E), (I), (J), (K), (L))

Actual and Reasonable Attorney Fees
Relocation Expenses
Increased Security (DV Cases)
Retrofit a Residence or Vehicle (Permanent Disability)
Monitor / Repair Credit (Identity Theft Cases)
Other Costs / Losses:

Please Describe – Additional Expenses

Please Upload any Documentation or Receipts

Drag & Drop Files, Choose Files to Upload You can upload up to 30 files.

Estimated Value of Loss

CLAIM TOTAL:

Are you requesting to assert your rights in court under Article 1, Section 28 of the California Constitution? (Also known as Marsy's Law) *

YES
NO

To Learn more about Marsy’s Law, CLICK HERE.

Date / Time *

Date

Time

Signature *

Clear Signature

For purpose of submitting my restitution claim, my typed e-signature shall have the same effect as my handwritten wet signature.

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