Criminal Rule 32.6(b)(3) CR-455 (/1)(cs)VICTIM RESTITUTION INFORMATION Page of VICTIM RESTITUTION INFORMATION (Confidential For Use Only by the Court) The purpose of this form is to provide confidential victim information to the Court to enable restitution payments to be made to the victims. Do NOT serve this form on the defendant or 1.The prosecutor must file this form with a proposed restitution judgment. The court willnot accept a proposed judgment without this form. 2.If a restitution judgment has already been entered, the prosecutor must submit thisform within 30 days. 3.If no district attorney participated in the case, the clerk must complete this form andforward it to the Fiscal Operations Restitution Unit with a copy of the restitutionorder/judgment. Immediately email this form to the Restitution Unit at restitution@akcourts.us . Destroy this document after emailing it. Original Victim Restitution Information Modification of Prior Victim Restitution Information Dated . Case Name: State of Alaska/City v. Case Number: CR Co-defendants and their case numbers: Total Restitution Due In This Case $ Victim A: Name Amount $ Date of Birth: SS# Claim/Acct Number*: Mailing Address: Phone Number: E-Mail Address: Victim B: Name Amount $ Date of Birth: SS# Claim/Acct Number*: Mailing Address: Phone Number: E-Mail Address: Victim C: Name Amount $ Date of Birth: SS# Claim/Acct Number*: Mailing Address: Phone Number: E-Mail Address: Date Print or Type Name *Include any claim or account number for insurance companies, banks, pawnshops, etc., if known. American LegalNet, Inc. www.FormsWorkFlow.com