CRM301 State ENG Rev 8/18 www.mncourts.gov/forms Page 1 of 1 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Criminal State of Minnesota vs. Affidavit for Restitution Minn. Stat. 247 611A.04 , Defendant I state the following losses were incurred, or the following property was damaged, stolen or destroyed by Defendant. List the value and/or damage of each property item. Also include other out of pocket losses resulting from the crime. (Attach estimates or receipts. Attach another sheet if necessary.) $ $ $ $ TOTAL: $ My losses/damages (were) (were not) covered by insurance. Name of insurance company Amount of deductible and / or uninsured loss: $ Claim No. Insurance claim has been submitted but has not been paid. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature County and State Where Signed: Name: Address: City/State/Zip: NOTE: This affidavit for restitution must be completed and returned to the court administrator. THIS DOCUMENT WILL BE PROVIDED TO THE DEFENDANT. Failure to claim restitution will not result in the loss of the right to pursue any other civil remedy available by law. American LegalNet, Inc. www.FormsWorkFlow.com