This form is to be used by a victim or authorized representative. Once approved, future restitution payments will be sent to the new address. This form may not be used to request a victim name change. Victim Name (as it appears in judgment) * Old Address Street Old Address City Old Address State Old Address Zip Old Phone Number Old Email Victim Representative Name, if request is being made by authorized representative of victim Relationship to Victim Parent Legal Guardian Legal Counsel Other If other, please specify relationship New Address Street New Address City New Address State New Address Zip New Phone New Email Criminal Case Number Defendant's Name By entering my name, I declare I am the victim named in a federal criminal judgment as being entitled to restitution payments. By entering my name I declare under penalty of perjury that the foregoing information and supporting documentation are true and correct By entering my name, I declare I am the authorized representative who was named in a federal criminal judgment as being entitled to restitution payments. By entering my name I declare under penalty of perjury that the foregoing information and supporting documentation are true and correct Additional Documentation Please attach any PDF files that you would like to supply as documentation for the change.Files must be less than 10 MB.Allowed file types: pdf.
