Affidavit of Losses Form




Contact Information


















Witnesses











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







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
























Lost Wages

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













Other Expenses

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





Recovery


























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