You are listed as a victim in this case. As a result, you are entitled to collect restitution, if the
defendant is convicted and placed on probation. According to the Indiana Code, the court will
base its restitution order on a variety of factors. You also may wish to file a civil lawsuit to
recover damages; however, the prosecutor’s Office cannot assist with that.
If you have paid or owe any money for bills because of this crime, please complete this form. If
you do not require restitution, you do not need to fill out this worksheet. It is important to be as
accurate and complete as possible. You must attach copies of any bills or other proof of
money you have spent. If the documentation is not provided the Court may not order restitution.
Use and attach additional pages if necessary.