Request Restitution Form

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*Defendant's First Name: M.I.: *Last Name:
 

*Complaint No.:

*Your First Name: M.I.: *Last Name:

 

Property: $
I am requesting restitution; however, at this time I do not have an exact dollar amount. I will be submitting a request as soon as I have receipts.
 		  
Vehicle Damage: $
Medical Bills: $
Funeral Expenses: $
Lost Wages: $
Insurance Deductible: $
Other: $
SUB-TOTAL: $
- Paid by Insurance: $
TOTAL RESTITUTION: $

Please provide copies of bills or other supporting documents within 10 days of submitting this form. You may provide copies by faxing them to the Victim Services Unit at 602-534-4540 or mailing them to:

Phoenix Prosecutor's Office
P.O. Box 4600
Phoenix, AZ 85030-4600
ATTN: Victim Services Unit

 

If you have questions or want to speak with an Advocate, contact the Victim Services Unit by calling 602-261-8192 or send an email here.

Before you submit this email form, you should be aware of the City's policy on the use of its email systems. The policy states that the email message you are about to send: (1) is subject to public disclosure under the Public Records Law, (2) is not private or confidential, and (3) is retained for one month.

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