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WILLIAM restitution

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									                                                                                                                             MARY VAIL WARE
VIRGINIA R. DIAMOND, Chairman
                                                COMMONWEALTH of VIRGINIA                                                             DIRECTOR
                                               CRIMINAL INJURIES COMPENSATION FUND
WILLIAM L. DUDLEY, JR., Commissioner
                                                         Post Office Box 26927
JAMES SZABLEWICZ, Chief Deputy
                                                       Richmond, Virginia 23261
 Commissioner                                                                                                            Toll Free (800) 552-4007


        RESTITUTION PAYMENT FORM

        Person filling out this form: _____________________________________ Date: _________________


        This is UNCLAIMED RESTITUTION:                             YES    NO        CICF Claim #: __________________


        Please complete this section to the best of your ability with the information you have.

        County:                        _______________________________________

        Amount of Check enclosed:                 $_______________              Unpaid Balance: $_________________

        Offender Name:                _______________________________________

        Victim Name:                   _______________________________________

        Intended recipient of restitution (if other than victim)   ____________________________________________

        Date of Crime:                 ________________                   Case Number:         _____________________

        I am:    Victim Witness            Probation         An Individual          Court:________________________



        ------------------------------------------------------------------------------------------------------------------------------




          To receive a receipt, please print your name                       CICF use:
                          and address:
                                                                             Amount Received: $__________

                                                                             CICF Staff:            __________

                                                                             Date Received:          __________

                                                                             BALANCE:                 ___________
        _____________________________

								
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