Form Center

Step One

Please list all items LOST or DAMAGED and the value of each item in the space below. Please include any out of pocket expenses. You must send in copies of your bills, receipts or estimates.
Enter Restitution Information Below*
Did your Insurance cover this loss?*
1. Yes
2. No
Continue |Go Back

I declare that the information contained on this form is true and correct to the best of my knowledge.
NEXT STEPS
I understand that by signing this form I will have to submit my receipts, bills or estimates to the Prosecuting Attorney's Office ASAP.
Electronic Signature*
Please type your full first and last name.
Date
SENDING IN YOUR BILLS, RECEIPTS, OR ESTIMATES
You can send in your bills, receipts or estimates in one of the following ways: Via E-mail to: millerj@co.cowlitz.wa.us Via Fax to: 360-414-9121 ATTN: Victim Services Division Via Mail to: Prosecuting Attorney's Office ATTN: Victim Services Division 312 SW First Ave, Kelso, WA 98626
ATTENTION
Please be advised that restitution can only be ordered for those losses directly attributed to the crime for which this defendant is convicted. Restitution is not guaranteed, nor can we guarantee the amount you will receive and/or the time in which you will receive payments. Please be advised that it is unlikely that you will receive a lump-sum payment for your restitution. Thank you.

Leave This Blank: