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Judicial District: Court File Number: Case Type: Criminal

State of Minnesota, Plaintiff vs.
,

Affidavit for Restitution Minn. Stat. §611A.04
Defendant

STATE OF MINNESOTA COUNTY OF _________________
(County where Affidavit signed)

) ) )

ss.

, being duly sworn, states the following losses were incurred, or the following property was damaged, stolen or destroyed by defendant. List the value and/or damage of each property item. Also include other out of pocket losses resulting from the crime. (Attach estimates or receipts. Attach another sheet if necessary.) $ $ $ $ $ $ $ TOTAL: $ My losses/damages (were) (were not) covered by insurance. Name of insurance company Policy No. Amount of deductible Claim No. and/or uninsured loss: $ Insurance claim has been submitted but has not been paid. Dated:
Signature (Sign only in front of notary public or court administrator.)

Name: Subscribed and sworn to before me this day of , . Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator

NOTE: This affidavit for restitution must be completed and returned to the court administrator not later than , . Failure to claim restitution will not result in the loss of the right to pursue any other civil remedy available by law.

CRM301

State

ENG

Rev 5/08

www.mncourts.gov/forms

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