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PROB 72 (7/96)

Page 1 of UNITED STATES DISTRICT COURT FOR THE CENTRAL DISTRICT OF ILLINOIS Declaration of Victim Losses

United States v.

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, residing at , in the city (or county) of , in the state of , am victim in the above-referenced case and I believe that I am entitled to restitution in the total amount of $ . My specific losses as a result of this offense are summarized as follows:

I,

I have been compensated by insurance or another source with respect to all or a portion . The name and address of my insurance company the of my losses in the amount of $ claim number for this loss is as follows:

Claim #:

I declare under penalty of perjury that the foregoing is true and correct.

(Signat ure)

Executed on _______ day of _______, _______
(Additional Pages May be Attached)