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Affidavit of Restitution

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  2. PRIOR TO COMPLETION OF THIS FORM, READ INSTRUCTIONS
  4. INSTRUCTIONS FOR FILING RESTITUTION AND AFFIDAVIT CLAIM FORM
    In the event you received this form from an investigating officer at the time of the incident, it must be filed within seven working days from the date of the incident with the Itasca County Court Administrator. In the event this form has been mailed to you by the prosecuting attorney and you have not already filed a Request for Restitution, it must be completed and mailed to the Itasca County Court Administrator within seven working days from the date of the enclosed victim notification letter. 2. ICR: This is the Initial Complaint Report (ICR) number which may have been supplied to you at the time of the incident; may be noted on correspondence if enclosed; or may be obtained through the law enforcement agency investigating this case. 3. Defendant’s Name: This is the person who is alleged to have committed the crime which resulted in your loss, damage, or injury. In the event this information is unknown to you, contact the investigating officer, the prosecuting attorney, or the Court Administrator. 4. Victim’s Name, Address, and Telephone Numbers: Phone numbers (both work and home) are necessary to assist prosecuting attorneys or Court Administration in contacting you. If you desire to keep your address and phone number confidential, please contact the Itasca County Attorney’s Office Victim Assistance Program. 5. Date of Loss: Alleged date of crime or loss. 6. Type of Loss/Crime Charged: Examples: theft, damage to property, assault, car accident. 7. Items or elements of the above loss are listed below. Supporting documents must be attached: A. Describe why restitution is appropriate in this case. 2. Itemize the total dollar amount of each item or element. 3. Attach supporting documents. Examples: 1. Attach any medical or therapy cost bills, phone bills, towing charge bills, estimates for repairs, copies of checks, receipts for any out-of-pocket expenses, documented mileage, etc. 2. Attach insurance claim forms indicating deductible amounts. 3. Attach documentation for replacement of lost wages and/or services. 8. Total Amount of Loss: Total dollar value of all items being claimed. 9. Insurance: This information is required and must be completed. 10. You must have your signature on this claim notarized. You must sign this form in front of the notary public.
  6. If you need assistance or have questions regarding completing this form, please contact:
    Dida Foster Itasca County Attorney’s Office Victim’s Assistance Program Coordinator 123 NE Fourth Street Grand Rapids, MN 55744 218-327-2804
  12. State of Minnesota, County of Itasca
  13. REQUEST FOR RESTITUTION AND AFFIDAVIT
  29. Supporting documents must be attached. Please itemize.
  33. 8. Insurance information must be completed.
  34. Insurance?
  36. If yes, provide insurance company name:
  44. Deductible:
  47. Have you submitted a claim to your insurance company?
  48. Has the claim been paid?
  51. The undersigned certifies that he/she has a just and true claim against the defendant(s) identified by the above information; and the information given is factual and true to the best of his/her knowledge.
  59. FAILURE TO HAVE YOUR SIGNATURE NOTARIZED COULD RESULT IN THE DENIAL OF YOUR CLAIM.
  61. Return to:
    Court Administrator, 123 NE Fourth Street, Grand Rapids, MN 55744, Phone 218-327-2870
    62. Leave This Blank:

  64. This field is not part of the form submission.