Fill and Sign the Destroyed by the Juvenile Named above Form

JUV101 State ENG Rev 8/1 8 www. mncourts. gov/forms Page 1 of 1 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Juvenile In Re Welfare of: , Affidavit for Restitution Minn. Stat. § 611A.04 I state the following losses were incurred, or the following pr operty was damaged, stolen or destroyed by the juvenile named above. 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 Amount of deductible and / or uninsured loss: $ Claim No.  Insur ance claim has been submitted but has not been paid. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated : Signature County and State Where Signed: Name: _____________________________ Address: City/State/Zip: NOTE: This affidavit for restitution must be completed and returned to the court administrator. THIS DOCUMENT WILL BE PROVIDED TO THE JUVENILE. Failure to claim r estitution will not result in the loss of the right to pursue any other civil remedy available by law.