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