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 complete 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: 1:16-cr-0031-1) Division Year (2 digit) Case No. Deft. No.
Defendant's Name: *, *
Last 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. Requestor's Information
Restitution Payee (Victim) Name: *
Counsel for the Victim
Defendant Company/Firm:
Counsel for Defendant
US Probation Officer
BOP Officer Address:*
City, State, Zip: *
Telephone: *
Request victim address change for restitution payments by email or mail through the U.S. Attorney's Office
Victim Address Change Form (Restitution)
C. Restitution Payment Information

Total of payments made Balance of payments due Last payment date Other (below)

    (Describe other requests here.)

D. Notification Method

Restitution payment information to be provided by:
U.S. Mail (at the address above)
In Person (at the USDC Clerk's Office)

E. Certification

Please read the following statement, then click "Certify the Form" before submitting the request.

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.

Please enter your name and date, then submit the form.

Full Name: Date:

Please do not click the "Submit" button more than once. Thank you.

  U.S. District Court, Southern District of Indiana ▪ Updated