Restitution – only fill out fields that apply

Property Damage

Please attach all relevant available documentation, such as estimates or bills, at the end of this form

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Medical Expenses

Include cost of prescription drugs, ambulance fees, hospital and laboratory bills,
and doctor bills

Please list name of service provider

Please attach all available bills at the end of this form

Hospital:

Hospital Expense Amount ($):

Doctor #1 Name:

Doctor #1 Expense Amount ($):

Doctor #2 Name:

Doctor #2 Expense Amount ($):

Ambulance:

Ambulance Expense Amount ($):

Prescriptions:

Prescriptions Expense Amount ($):

Other:

Other Expense Amount ($):

Lost Wages

Please attach letter from employer or last two pay stubs at the end of this form

Days Missed:

Net Pay ($):

Employer Name:

Employer Address:

Employer Phone:

Employer Contact Full Name:

I received paid leave (sick leave, annual leave, vacation, etc) while off from work

Other Expenses

List additional expenses or losses that you have incurred as a result of the criminal act

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Recovery

Medical Insurance Name:

Medical Insurance Address:

Medical Insurance Phone:

Medical Insurance Policy #:

Medical Insurance Recovery Amount ($):

Property Insurance Name:

Property Insurance Address:

Property Insurance Phone:

Property Insurance Policy #:

Property Insurance Recovery Amount ($):

Value of Recovered Property ($):

Other Recovery ($):

Upload Files (jpg/png/pdf):

Victim Rights Request and Waiver Form

CONSTITUTIONAL AMENDMENT

VICTIMS OF CRIME OR THEIR LAWFUL REPRESENTATIVES, INCLUDING THE NEXT OF KIN OF HOMICIDE
VICTIMS, ARE ENTITLED TO THE RIGHT TO BE INFORMED, TO BE PRESENT, AND TO BE HEARD WHEN
AUTHORIZED, AT ALL CRUCIAL STAGES OF THE CRIMINAL PROCEEDINGS, TO THE EXTENT THAT THESE
RIGHTS DO NOT INTERFERE WITH THE CONSTITUTIONAL RIGHTS OF THE ACCUSED. Act # 95-583; State of
Alabama

I have received the printed pamphlet advising me of my constitutional rights and

I wish to exercise them fully and be notified of every hearing

I wish to be notified only when my attendance is required

Victim Date of Birth:

Victim Social Security Number:

Victim Driver’s License Number:

Victim Driver’s License State:

Family Contact Full Name:

Contact Person Date of Birth:

Contact Person Social Security Number:

Contact Person Driver License Number:

Contact Person Driver License State:

Contact Person Cell Phone:

Contact Person Secondary Phone:

Witness Full Name:

Witness Address:

Witness City:

Witness State:

Witness Zip Code:

Witness Cell Phone:

Witness Secondary Phone: