Minnesota > Statewide > District Court > Juvenile
Affidavit For Restitution JUV-101 - Minnesota
| Affidavit For Restitution Form. This is a Minnesota form and can be used in Juvenile District Court Statewide . |
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State of Minnesota County Judicial District: Court File Number: Case Type: District Court Juvenile In Re Welfare of: , Affidavit for Restitution Minn. Stat. ยง611A.04 , being duly sworn, states the following losses were incurred, or the following property was damaged, stolen or destroyed by , juvenile. 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. Claim No. Amount of deductible 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: Sworn/affirmed before me this day of , . Address: 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 , . Failure to claim restitution will not result in the loss of the right to pursue than any other civil remedy available by law. JUV101 State ENG Rev 12/01 www.courts.state.mn.us/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com
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