Victim’s Restitution Statement | Washington County of Utah

In every criminal case, a victim is entitled to request restitution when the restitution is directly or indirectly caused by the criminal act of the defendant.

For any restitution request, please fill out the restitution form. If you have repaired or replaced any item(s) keep the receipts as we require supporting documentation (receipts, estimates, bills) to be provided to this office. Please also indicate if an insurance claim has been submitted, and if so, please provide documentation of any applicable deductible. Unfortunately, damages due to emotional pain and suffering are only available through the civil courts, and not through criminal restitution.

You may include any additional information with your return packet. Please note it is critical that you submit the restitution documentation and requested amount at your earliest convenience. Failure to do so may result in RESTITUTION NOT BEING ORDERED. You would then have to pursue it civilly.

NOTE: After submitting your form, our staff may each out for further documentation and/or evidence.

Printable Form
Web Form

- Step 1 of 14

State vs. *

Case Number *

Victim's Name *

First

Middle

Last

Date of Birth *

MM/DD/YYYY

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address is different than Home Address

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home/Cell Phone *

Place of Work

Work Phone

Email *

Next-of-Kin *

First

Middle

Last

Next-of-Kin Relationship

Next-of-Kin Phone

Please describe the type of offense in which you were a victim: *

As a result of this crime, were you physically injured? *

If yes, describe the extent of your injuries. *

Did you require medical treatment? *

If yes, list the amount of expenses incurred to date as a result of this incident *

If total amount is unknown at this time, what amount is anticipated. *

Medical bills, and a copy of treatment plan for the future. *

Yes, I will send them via email.
Yes, I will mail them via postal service.
Yes, I will deliver them via in-person.
No, I do not have copies to send.

Washington County Attorney’s Office
Attn: Victim Services
33 North 100 West, #200
St. George, Utah 84770
(Google Maps)
victim.services@wcattorney.com

Will you have ongoing medical treatment or physical therapy or counseling? *

Were any of your medical expenses covered by insurance? *

If yes, how much has been paid by the insurance company? *

Insurance Company *

Policy Number *

Agent's Name *

First

Middle

Last

Agent's Phone *

Insurance Company's Address

Address Line 1

Address Line 2

City

State

Zip Code

What is your Total amount of Out of Pocket Expenses to date? *

Did you suffer any monetary loss, property loss, or property damage due to this crime? *

Describe what was lost, damaged, or repaired *

Do not include property that is held in evidence or located at a pawn shop, list only property or loss that was not recovered. List each item below including the value.

Copy of estimate or bill of repairs *

Yes, I will send them via email.
Yes, I will mail them via postal service.
Yes, I will deliver them via in-person.
No, I do not have copies to send.

What is the TOTAL amount of restitution you are claiming? *

Were any of your property losses or damages covered by insurance? *

If yes, how much have you received from your insurance company? *

How much was your deductible? *

Insurance Company *

Agent Name *

First

Middle

Last

Agent Phone *

Agent Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance documentation or other information itemizing such losses *

Yes, I will send them via email.
Yes, I will mail them via postal service.
Yes, I will deliver them in-person.
No, I do not have copies to send.

Washington County Attorney’s Office
Attn: Victim Services
33 North 100 West, #200
St. George, Utah 84770
(Google Maps)
victim.services@wcattorney.com

Was any of your property recovered by the police and returned to you? *

Is any of your property being held by police in evidence? *

List items that were returned to you or that are being held in evidence. *

Was any of your property held b a Pawn Shop? *

If so, did you pay the Pawn Shop and retrieve your property? *

How much did you pay the Pawn Shop? *

List all items that are still being held at the Pawn Shop *

Did you have fraudulent charges to your bank account, debit card, or credit card? *

If yes, were these fraudulent charges covered by your bank or your credit card company? *

If yes, please provide the name of your bank or credit card company, your account number, date and amount of the fraudulent charge and their fraud department phone number. *

Has this crime affected your ability to earn a living? *

If yes, please describe your employment and specify how and to what extent your ability to earn a living has been affected (days lost from work, wage loss, etc.). *

Appropriate documentation regarding your losses. *

Yes, I will send them via email.
Yes, I will mail them via postal service.
Yes, I will deliver them via in-person.
No, I do not have copies to send.

Washington County Attorney’s Office
Attn: Victim Services
33 North 100 West, #200
St. George, Utah 84770
(Google Maps)
victim.services@wcattorney.com

Has this crime in any way affected your lifestyle or your family’s lifestyle or caused any lasting effects for you or your family? *

If yes, please explain *

Digital Signature *

I hereby authorize and certify the above to be true.

Full Legal Name *

First

Middle

Last

Date *

MM/DD/YYYY