STATE OF MAINE DISTRICT COURT Location Docket No. Creditor/Victim REQUEST FOR RESTITUTION ORDER TO BE MADE A MONEY JUDGMENT 17-A M.R.S. § 1330-C v. Debtor/Defendant NOW COMES , creditor/victim, and requests an order of restitution be issued against the above named debtor/defendant and be deemed a money judgment. Address of Creditor/Victim: Telephone: Docket # underlying criminal matter: Name of defendant: DOB defendant: Date: Signed: Creditor/Victim ORDER It is hereby ORDERED that the debtor/defendant pay the creditor/victim the amount of restitution listed on the Judgment and Commitment form. , Date: Clerk, Maine District Court MJ-014, Rev. 9/15 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com