Exempt from VRA Conf. Page VICTIM INFORMATION STATEMENT (Confidential ­ For Use Only by the Court or DOL Collections Unit) of The purpose of this form is to provide confidential victim information to the Court or the Department of Law to enable restitution payments to be made to the victims. Do NOT serve this form on the defendant or defendant's attorney. This form is to be used in the following cases when restitution is ordered: 1. In ALL municipal criminal cases. It must be filed by the Municipal Prosecutor either: a. Within 15 days from entry of any Restitution Judgment entered at the time of sentencing; OR b. At the time the prosecutor submits a proposed Restitution Judgment to the court. 2. In state criminal cases when no District Attorney participated in the case. The clerk must complete this form and forward it with a copy of the restitution order/judgment to the Department of Law. Original Victim Information Statement Case Name: Case Number: Co-defendants and their case numbers: Total Restitution Due In This Case $ State of Alaska/City v. Modification of Prior Victim Information Statement Dated . CR Victim A: Name Amount $ Date of Birth: SS# Claim/Acct Number*: Mailing Address: ____________________________________ Prosecutor's Reference Number: Victim B: Name Amount $ Date of Birth: SS# Claim/Acct Number* Mailing Address: ____________________________________ Prosecutor's Reference Number: Victim C: Name Amount $ Date of Birth: SS# Claim/Acct Number*: Mailing Address: ____________________________________ Prosecutor's Reference Number: Date Signature and Title Print or Type Name: *Include any claim or account number for insurance companies, banks, pawnshops, etc., if known. CR-455 (12/01)(cs) VICTIM INFORMATION STATEMENT Criminal Rule 32.6(b)(3) American LegalNet, Inc. www.FormsWorkFlow.com