State of Minnesota
Judicial District: Court File Number: Case Type: Juvenile
In Re Welfare of:
Affidavit for Restitution Minn. Stat. §611A.04
STATE OF MINNESOTA
) ) COUNTY OF _________________)
(County where Affidavit signed)
, 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.
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.
Page 1 of 1