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STATE OF SOUTH CAROLINA COUNTY OF

) ) )

IN THE MAGISTRATES COURT

VS.

) ) ) ) ) ) ) ) ) DEFENDANT(S) )

ORDER OF RESTITUTION TO STATE OFFICE OF VICTIMS ASSISTANCE

TICKET/WARRANT NUMBER

Defendant in the above named case was found/pled guilty or nolo contendre of the charge of and, in addition to any sentence imposed, is ordered by this Court to pay restitution in the amount of $ monies expended on behalf of the Victim, . The ordered restitution is reimbursement for , by the State

Office of Victims Assistance, as a direct result of defendant's criminal misconduct. Pursuant to § 22-3550, ordered restitution may not exceed $5,000.00 and an itemization of the amount of restitution is attached hereto and made a part of this Order. Payments shall be made in the amount of $ per month/week, or paid in full by

. Defendant shall make payment by cashier's check or money order in the name of the State Office of Victims Assistance and mailed to: SOVA, Restitution Department, 1205 Pendleton Street, Room 401, Columbia, South Carolina, 29201. Personal checks or cash will not be accepted by mail. Failure to pay the above stated amount of Restitution within the time provided may result in contempt of court, punishable by a fine not to exceed $500.00, or imprisonment not to exceed thirty days, or both. Special Instructions as Ordered:

Signature of Presiding Judge

Date

SCCA/640 (Amended 7/15/05)