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RE: CAYLAN NICOLL <br /> Cr. No.: 05-1-077 <br /> Victim: Mayor's Office (C of H) <br /> RESTITUTION CLAIM <br /> ITEM MODEL NO. DATE OF PURCHASE PURCHASE REPLACEMENT/ <br /> HOW OLD IS ITEM PRICE REPAIR COST <br /> For additional space, please use another sheet. Also Note: For Victim's Statement, please use the other <br /> form provided. <br /> INSURANCE COVERAGE? Company Deductible S <br /> Claims Adjuster Phone No. <br /> I acknowledge that the above information is accurate and true to the best of my knowledge. <br /> SIGNATURE Date: <br /> PLEASE RETURN THE RESTITUTION CLAIM AND VICTIM'S STATEMENT TO: <br /> PROBATION OFFICER, ARLENE AWA MASU LIT 1045-A Kilauea Avenue, Hilo, HI 96720 <br />