Free Microsoft Word - JUV101 - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type: Juvenile

Select County
In Re Welfare of:
,

Affidavit for Restitution Minn. Stat. §611A.04

STATE OF MINNESOTA

) ) COUNTY OF _________________)
(County where Affidavit signed)

ss.

, being duly sworn, states the following losses were incurred, or the following property was damaged, stolen or destroyed by ____________________________________, juvenile. List the value and/or damage of each property item. Also include other out of pocket losses resulting from the crime. (Attach estimates or receipts. Attach another sheet if necessary.) $ $ $ $ $ $ $ $0

TOTAL: My losses/damages (were) (were not) covered by insurance. Name of insurance company Policy No. Claim No.

Amount of deductible and/or uninsured loss: $

Insurance claim has been submitted but has not been paid.

Dated:
Signature (Sign only in front of notary public or court administrator.)

Name: Subscribed and sworn to before me this day of , . Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator

NOTE: This affidavit for restitution must be completed and returned to the court administrator not later , . Failure to claim restitution will not result in the loss of the right to pursue than any other civil remedy available by law.

JUV101

State

ENG

Rev 8/08

www.mncourts.gov/forms

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