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Affidavit of Loss - 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 IN THE MUNICIPAL COURT OF THE CITY OF KALISPELL FLATHEAD COUNTY, STATE OF MONTANA CITY OF KALISPELL, Plaintiff, vs. Defendant Name: Defendant. : : : : : : : : : : Case No.: Kalispell Police Department Report No.: AFFIDAVIT OF LOSS AND REQUEST FOR RESTITUTION STATE OF MONTANA ) )ss. County of Flathead ) , being first duly sworn upon his oath, deposes and Name says: 1. I am an adult resident of I am percipient and if called upon to testify could testify to the following, all of which are within my own personal knowledge. 2. I am the victim of the offense charged in this matter or I am the authorized representative of the victim of the offense charged. I am knowledgeable of the facts of this case and am able to testify to the loss sustained in this matter and make this request under authority of §46-18-241, M.C.A. 3. On I or my employer sustained a pecuniary loss due to the offense committed by the Defendant in this matter. 4. After diligent search I have concluded that the actual monetary loss sustained in this matter by me or my employer amounts to the sum of I have documentation to support this request, which is attached; I do not have documentation to support this request. ---PAGE BREAK--- Affidavit of Loss - 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 5. On behalf of me or my employer, a Court award of restitution in the amount referenced above is hereby requested. Dated this day of By: State of Montana County of Subscribed and sworn to before me this day of by . (Print name of signer) NOTARIAL SIGNATURE AND SEAL Affidavit of Loss and Request for Restitution