Restitution Worksheet

Name*
First Last
Email
Phone
Cause Number
Property Damage
Please list any personal property or belongings that were lost, destroyed, or damaged as a result of this crime, then record the value of the property. If you did not experience any property damage, please continue to part two of the worksheet. Up to eight items. Start with item 1 below.
Item 1

Do not use the $ sign, commas or periods. For example, one hundred dollars should read 100.
1. Value of loss or cost of repair
Item 2
2. Value of loss or cost of repair
Item 3
3. Value of loss or cost of repair
Item 4
4. Value of loss or cost of repair
Item 5
5. Value of loss or cost of repair
Item 6
6. Value of loss or cost of repair
Item 7
7. Value of loss or cost of repair
Item 8
8. Value of loss or cost of repair
TOTAL LOSS

Medical Expenses
Please list any medical expenses or hospital costs incurred as a result of the crime. If you did not have any medical expenses or hospital costs, please continue to the next page. Starting below, give a brief description of treatment.
1. Treatment

Do not use the $ sign, commas or periods. For example, one hundred dollars should read 100.
1. Expense
2. Treatment
2. Expense
3. Treatment
3. Expense
4. Treatment
4. Expense
5. Treatment
5. Expense
6. Treatment
6. Expense
7. Treatment
7. Expense
8. Treatment
8. Expense
TOTAL EXPENSES
Expected FUTURE expenses

Additional expenses
If there were any other expenses incurred, please list and describe below.
1. Additional expense

Do not use the $ sign, commas or periods. For example, one hundred dollars should read 100.
1. Amount
2. Additional expense
2. Amount
3. Additional expense
3. Amount
4. Additional expense
4. Amount
5. Additional expense
5. Amount
TOTAL ADDITIONAL EXPENSES

Insurance Information
If you have already received benefits or payments, or paid a deductible, please indicate that information below.
Property, Auto or Homeowners Insurance company name
Phone
Amount received
Deductible paid
Medical insurance company name
Phone
Amount received
Deductible paid
Thank you for taking the time to complete this form. Remember to attach copies of your bills or proof of money you have spent. If you have any questions or concerns, please do not hesitate to contact Victims Assistance at the Hancock County Prosecutor’s Office by calling (317) 477-1139 ext. 4030 Please understand that the Prosecutor’s Office cannot ask for pain and suffering damages. You would have to file a civil lawsuit. Please remember if the Defendant is sent to prison, then restitution may not be ordered.
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Property Damage