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Declaration Of Victim Losses Prob 72 - Illinois
|Declaration Of Victim Losses Form. This is a Illinois form and can be used in DISTRICT-WIDE USDC Central Federal .||
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PROB 72 (7/96) Page 1 of UNITED STATES DISTRICT COURT FOR THE CENTRAL DISTRICT OF ILLINOIS Declaration of Victim Losses United States v. ) ) ) ) ) , residing at , in the city (or county) of , in the state of , am victim in the above-referenced case and I believe that I am entitled to restitution in the total amount of $ . My specific losses as a result of this offense are summarized as follows: I, I have been compensated by insurance or another source with respect to all or a portion . The name and address of my insurance company the of my losses in the amount of $ claim number for this loss is as follows: Claim #: I declare under penalty of perjury that the foregoing is true and correct. (Signat ure) Executed on _______ day of _______, _______ (Additional Pages May be Attached) 2002 © American LegalNet, Inc.