Filing a Request for Restitution with the OVR

Date:
Name of crime victim. If victim is deceased, list the name here:


Victim's Date of Birth:
Is the person filling out this form different from the victim listed above?
Complete mailing address:




Cell phone:

Home phone:

Work Phone:

E-mail address:
Defendant's name and/or Court Case Number (example: 3AN-14-12345CR):

Was restitution ordered in the case listed above?


AGREEMENT

The Office of Victims' Rights (OVR) will maintain confidentiality with respect to all matters, including your identity, and that of witnesses coming before the OVR except insofar as, in the judgment of the OVR, disclosures are authorized by law and/or as may be necessary in order to enable this office to carry out its duties and to support its recommendations. This means that in the course of processing this complaint - request for assistance form and/or providing services in this case, it may become necessary for the OVR to use your name and/or other information about your case that you have provided, or which was acquired by the OVR in the discharge of our official duties, as a result of submitting this complaint - request for assistance form to us. By signing below you are agreeing that, in the judgment of the OVR, we may use your name and discuss and/or disclose information and/or documents and/or the facts of this case with others, including but not limited to others within the executive, legislative, or judicial branches of government, private or public agencies or offices, in open court and/or to the general public, or others, in the formulation of our findings and recommendations and in the discharge of our duties. The services of the Office of Victims' Rights are free.

Electronic Signature

I Agree
Social Security, Operator's License Or Other Unique Identifier:* (This is an electronic signature that will be used to verify your identity when we contact you)