REQUEST FOR CRIMINAL CASE
PAYMENT INFORMATION

Note: Pursuant to regulations adopted by the Judicial Conference of the United States, information regarding restitution payments made in criminal 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 criminal case number AND defendant's name, OR provide the check number of the U.S. Treasury check you have received.
Criminal Case Number and Defendant's Name
Criminal Case Number: *:         * - cr -  *   -
(Example: 1:12-cr-0031-1) Division Year (2 digit) Case No. Deft. No.
Defendant's Name: *, *
Last First Middle

U.S. Treasury check number

For restitution victim U.S. Treasury Check information, enter U.S. treasury check number: 4628 - *
B. Requestor's Information
Restitution Payee (Victim) Name: *
Defendant
Counsel for Defendant Company/Firm:
US Probation Officer
BOP Officer Address:*
City, State, Zip: *
Telephone: *
This is a change in Payee or Defendant address information.
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:
Email
FAX
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 criminal 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 criminal 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