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Douglas County District Attorney Victim/Witness Services 1313 Belknap Street Room #203 Superior, Wisconsin 54880 Phone # (715) 395-1349 Fax # (715) 395-1481 Restitution Request Form YOUR NAME: Complete the following section if you are claiming a financial loss due to this crime. Attach copies of bills or receipts. The court may not consider items without receipts. Medical Expense $ , . Funeral Expense $ , . Property Repair $ , . Property Replaced $ , . Counseling Costs $ , . Money stolen $ , . Checks Stolen $ , . Lost Wages $ , . Total Loss Claimed $ , . Total paid by insurance $ , . Insurance Company Name Insurance Company Address Insurance Agent Name Telephone Number Your Signature Please Date Please return this request form to : Victim/Witness Assistance Services Douglas County District Attorney Office 1313 Belknap Street Room #203 Superior, Wisconsin 54880