Declaration Of Victim Losses
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Declaration Of Victim Losses Form. This is a Illinois form and can be use in USDC Central Federal.
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Tags: Declaration Of Victim Losses, Prob 72, Illinois Federal, USDC Central
PROB 72
(7/96)
Page 1 of
UNITED STATES DISTRICT COURT
FOR THE
CENTRAL DISTRICT OF ILLINOIS
Declaration of Victim Losses
United States
)
)
)
)
)
v.
I,
, residing at
, in the city (or county) of
, in the state of
, am victim in the above-referenced case and I believe that I am entitled to restitution in the
total amount of $
.
My specific losses as a result of this offense are summarized as follows:
I have been compensated by insurance or another source with respect to all or a portion
. The name and address of my insurance company the
of my losses in the amount of $
claim number for this loss is as follows:
Claim #:
I declare under penalty of perjury that the foregoing is true and correct.
(Signat ure)
Executed on
_______ day of _______, _______
(Additional Pages May be Attached)
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