File No. STATE OF NORTH CAROLINA CountyIn The General Court Of Justice District Superior Court DivisionSTATE VERSUS RESTITUTION WORKSHEET, NOTICEAND ORDER(INITIAL SENTENCING)G.S. 15A-1340.34 through -1340.38, 15A-1343(d)Name And Address Of Defendant I. TOTAL RESTITUTION TO BE PAID BY DEFENDANT II. VICTIMS222 RIGHTS ACT (VRA) VICTIMSNOTE: Enter total restitution from Parts II - IV. The clerk should enter the total as 223Restitution224 on the Judgment Suspending Sentence or Judgment and Commitment. If total granted differs from total requested, enter only the total granted on the judgment. See attached AOC-CR-611A for additional victims/aggrieved parties. NOTE: List each victim of an offense listed in G.S. 15A-830(a)(7) 223directly and proximately harmed as a result224 of the offense. G.S. 15A-1340.34(a). Record each such victim222s SSN or Taxpayer ID on the AOC-CR-382 for the bookkeeping department. Requested:$$Granted, If Different: VRA VICTIM INFORMATION (NOTE: If victim has refused to disclose any information, so state.)RESTITUTION AMOUNT Name And AddressContact PersonTelephone No.Requested:Account No.Granted, If Different:RaceSexDOBDocketing InfoAbs. No. $$ The defendant is held jointly and severally liable to this victim with the following person(s), as provided in any order(s) for restitution against them (enter names of other defendants and file numbers; if no file numbers assigned, enter law enforcement agency and incident number): . The defendant is held jointly and severally liable to this victim with the following person(s), as provided in any order(s) for restitution against them (enter names of other defendants and file numbers; if no file numbers assigned, enter law enforcement agency and incident number): . Name And AddressContact PersonTelephone No.Requested:Account No.Granted, If Different:RaceSexDOBDocketing InfoAbs. No. $$ III. OTHER VICTIMS (NON-VRA)NOTE: List each victim of an offense other than one listed in G.S. 15A-830(a)(7) 223directly and proximately harmed as a result224 of the offense. G.S. 15A-1340.34(a). Record each such victim222s SSN or Taxpayer ID on the AOC-CR-382 for the bookkeeping department. VICTIM INFORMATIONRESTITUTION AMOUNT The defendant is held jointly and severally liable to this victim with the following person(s), as provided in any order(s) for restitution against them (enter names of other defendants and file numbers; if no file numbers assigned, enter law enforcement agency and incident number): . Name And AddressContact PersonContact PersonTelephone No.Requested:Account No.Granted, If Different: $$ The defendant is held jointly and severally liable to this victim with the following person(s), as provided in any order(s) for restitution against them (enter names of other defendants and file numbers; if no file numbers assigned, enter law enforcement agency and incident number): . Name And AddressTelephone No.Requested:Account No.Granted, If Different: $$ (Over) American LegalNet, Inc. www.FormsWorkFlow.com IV. OTHER AGGRIEVED PARTIES (NON-VICTIMS)NOTE: List each aggrieved party other than a victim entitled to restitution pursuant to G.S. 15A-1340.37. Record each such party222s SSN or Taxpayer ID on the AOC-CR-382 for the bookkeeping department. AGGRIEVED PARTY INFORMATIONRESTITUTION AMOUNT Name And AddressContact PersonTelephone No.Requested:Account No.Granted, If Different: $$ The defendant is held jointly and severally liable to this party with the following person(s), as provided in any order(s) for restitution against them (enter names of other defendants and file numbers; if no file numbers assigned, enter law enforcement agency and incident number): . Name And AddressContact PersonTelephone No.Requested:Account No.Granted, If Different: $$ The defendant is held jointly and severally liable to this party with the following person(s), as provided in any order(s) for restitution against them (enter names of other defendants and file numbers; if no file numbers assigned, enter law enforcement agency and incident number): . V. ORDER AND JUDGMENT FOR RESTITUTION The Court, having considered the information presented by the parties about the loss or damage caused by the offense(s) of which the defendant has been convicted and about the defendant222s ability to make restitution, ORDERS that: 1. The defendant pay to each victim and aggrieved party named in Parts II - IV the 223Restitution Amount224 shown for each such entity. If the defendant is sentenced to active punishment, such amounts shall be payable only if recommended as a condition of post-release supervision or parole or from work release earnings or if ordered docketed as a civil judgment in No. 5 below. 2. The amount(s) awarded is full restitution for each victim or party except as described below for any party awarded partial restitution (state reasons for ordering partial restitution to any victim or aggrieved party, G.S. 15A-1340.36(a)): . 3. The defendant was ordered to pay restitution as a condition of probation. 4. (Check when awarding restitution under Part II for a misdemeanor.) The defendant was convicted of committing a misdemeanor listed in G.S. 15A-830(a)(7)g. II, that the clerk docket a civil judgment against the defendant in favor of such victim and for the 223Restitution Amount224 granted. G.S. 15A-1340.38(b). NOTE TO CRIMINAL CLERK: docketed for an award in Part II, provide a copy of this form to your civil department. Attach a copy of this form to the judgment and mail to the Division of Adult Correction and Juvenile Justice, Combined Records, 2020 Yonkers Road, 4226 MSC, Raleigh, NC 27699-4226, or other agency receiving custody of defendant. G.S. 15A-832(g).NOTE TO BOOKKEEPER: On the bill of costs in the Financial Management System, enter restitution information, along with information from the criminal (2) placed on supervised or unsupervised probation, or (3) sentenced to an active sentence and the Court recommends the payment of any amount as a condition of post-release supervision or parole or from work release earnings. Unless otherwise ordered, use account code 26120, distribution priority 1, for each victim awarded restitution in Parts II and III, and use distribution priority 5 for non-victims awarded restitution in Part IV.NOTE TO CIVIL CLERK: For each victim listed in Part IIabstract a judgment against the defendant in Judgment Abstracting in favor of the victim. Enter all such judgments under the CR/CRS number for this case, and enter a separate 223VRST224 issue for each victim. In addition, if the defendant was ordered to pay restitution as a condition of probation (see Order No. 3 above): (1) make the entries necessary to indicate that interest does not accrue and execution may not issue, (2) enter the JA Abstract Number(s) in Part II, above, and (3) forward a copy to your bookkeeper. DateName Of Judge (type or print)Signature Of Judge AOC-CR-611, Side Two, Rev. 4/18 American LegalNet, Inc. www.FormsWorkFlow.com