test - Pinal County Attorney's Office

Defendant's Name

Case type(Required)

Case #(Required)

I (Name Below) am the victim in the above-entitled case.(Required)

First Last

As a direct result of this crime I have suffered the following economic losses:

Medical, Hospital and Counseling Bills:

Repairs:

Damages:

Items Stolen

Other (do not include non-economic losses such as 'pain and suffering' and 'mental anguish')

Deductible:

Total Loss:

Restitution Request(Required)

I am requesting restitution for my losses

I am not requesting restitution for my losses

If not requesting restitution for my losses. Please explain:

Insurance(Required)

I do not have insurance

I do have insurance

My insurance company has reimbursed me in the amount of:

The name and address of my insurance company is:

The name of my insurance agent:

I have paid an insurance deductible in the amount of:

The insurance claim number is:

Crime Victim Compensation

I have submitted an application for Crime Victim Compensation

ANY AND ALL DOCUMENTS THAT SUPPORT THE ABOVE LOSSES SHOULD BE ATTACHED TO THIS FORM AND SENT TO:

VICTIM SERVICES DIVISION

PINAL COUNTY ATTORNEY'S OFFICE

POST OFFICE BOX 1010

FLORENCE, ARIZONA 85132

pcavictimservices.sharedmailbox@pinal.gov

File

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To the best of my knowledge, the information, the amounts and figures set forth herein represent my losses as result of the above reference crime.

Date

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