United States District Court for the Southern District of Indiana
__________________________________________________________________
REQUEST CASE
PAYMENT INFORMATION
NOTE: Pursuant to regulations adopted by the Judicial Conference of the United States, information regarding
restitution payments made in cases is not available to the public and may only be provided to the restitution payee
(victim), to the defendant, or to counsel of record for the defendant.
Please complete all form fields; * indicates a required field.
______________________________________________________________________________
A. CASE INFORMATION
Please provide the case number AND defendant's name OR provide the check number
and check date of the U.S. Treasury check you have received.
Case Number and Defendant's Name
Case Number: * _____: *_______ - cr - *___________ - ______
(Example: 1:23-cr-012-1) Division* Year (2 digit) Case No. Deft. No.
*Division: 1 = Indianapolis; 2 = Terre Haute; 3 = Evansville; 4 = New Albany
Defendant's Name: * ____________________ *________________ _______
Last Name First Middle
U.S. Treasury check number and date
For restitution victim U.S. Treasury Check information:
Enter U.S. treasury check number: *____________________
Enter U.S. treasury check date (MM/DD/YY): *__________________
______________________________________________________________________________
B. REQUESTER'S INFORMATION
Restitution Payee
(Victim) Name*
Counsel for the Victim
Company/Firm:
Defendant
Address*:
Counsel for Defendant
U.S. Probation Officer
City, State, Zip*:
BOP Officer
Telephone*:
This is a change in Payee or Defendant address information.
NOTE: Request victim address change for restitution payments by email or mail through the U.S. Attorney's Office
Victim Address Change Form (Restitution)
United States District Court for the Southern District of Indiana
__________________________________________________________________
______________________________________________________________________________
C. CRIMINAL DEBT/RESTITUTION PAYMENT INFORMATION
Total of Payments Made to the Clerk's Office
Last Payment Date
Other: ________________________________________________________
______________________________________________________________________________
D. NOTIFICATION METHOD
Please select the delivery method below for restitution payment information.
Email: _______________________________ (provide email address)
Fax: _______________________________ (provide fax number)
U.S. Mail (at address above)
In Person (at the USDC Clerk's Office)
______________________________________________________________________________
E. CERTIFICATION
Please read the following statement, then certify by placing an "x" in the box next to the
certification statement and enter the date and apply your signature in the spaces
provided below. Once complete, please click the "Submit" button.
I understand that requests for case information must be processed under the Subpoena
Regulations Adopted by the Judicial Conference of United States Courts and that information
may only be released to the case restitution payee (victim), the defendant or counsel of record
for the defendant. I declare under penalty of perjury under the laws of the United States of
America that the information I have provided on this form is true and correct and would be
my testimony if I were in a court of law.
Date: ___________________ ______________________________________________
Signature*
*For electronic signatures, please type "s/" before typing your name. Example, "s/John Doe"
Submit
SUBMIT
If the "Submit" button does not work with your settings, please save this document once completed and email it as an attachment
to
[email protected].
