Affidavit For Restitution - Minn. Stat. 611a.04

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State of Minnesota
District Court
County
Judicial District:
Court File Number:
Select County
Case Type:
Criminal
State of Minnesota,
Plaintiff
Affidavit for Restitution
vs.
Minn. Stat. §611A.04
,
Defendant
STATE OF MINNESOTA
)
)
ss.
COUNTY OF _________________
)
(County where Affidavit signed)
, being duly sworn, states 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
Policy No.
Amount of deductible
Claim No.
and/or uninsured loss: $
 Insurance claim has been submitted but has not been paid.
Dated
:
Signature (Sign only in front of notary public or court administrator.)
Name:
Subscribed and sworn to before me this
Address:
day of
,
.
City/State/Zip:
Telephone:
Notary Public \ Deputy Court Administrator
NOTE: This affidavit for restitution must be completed and returned to the court administrator not later
than
,
. Failure to claim restitution will not result in the loss of the right to pursue
any other civil remedy available by law.
CRM301
State
ENG
Rev 5/08
Page 1 of 1

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