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Glendale, AZ
Victim Information

If your address or telephone number changes, you must notify the prosecutor to continue to receive notices or assistance. Fields marked with a '*' are required.

Please note: This form is a secure form, however, we cannot control the security levels on your personal computer. Please be aware that your computer may retain a record of your use of this form (in the form of a history or cookies). For instructions on how to delete your computer's cookies or history, please click here.

Your Personal Contact Information:
*First Name MI *Last Name
*Address 1
 Address 2
*City *State *Zip
Daytime Phone
Message Phone
E-Mail
(When you submit this form, your e-mail address is not provided to our Office. If you would like us to contact you by email and feel safe to do so, please provide us an email address. Note: this address will not remain confidential. To ensure confidentiality, mail your comments to Victim Services Unit, P.O. Box 4600, Phoenix, AZ 85030-4600.)

Complaint Information:
Defendant:
First Name MI Last Name
Complaint Number:
Police Report Number:

Check the items on which you want prosecutor assistance:
Notice of the date, time and location of each court hearing
Confer with the prosecutor
Restitution
Keeping my personal information that could be used to locate me confidential from the defense attorney and defendant

Restitution:

If requesting restitution, complete the section below and mail copies of bills for all losses claimed to:

Glendale City Prosecutor's Office
Victim Services Unit
6815 N. 57th Ave.
Glendale, AZ 85301
Phone: 623-930-3475

I am requesting restitution, however, at this time I do not have an exact dollar amount. I will be submitting a request as soon as I have receipts.
Property: $
Vehicle Damage: $
Medical Bills: $
Funeral Expenses: $
Lost Wages: $
Insurance Deductible: $
Other: $
SUB-TOTAL: $
- Paid by Insurance: $
TOTAL RESTITUTION: $

If you have questions concerning how to complete this form, call (623) 930-3475.

Before you submit this e-mail form, you should be aware of the City's policy on the use of its e-mail systems. The policy states that the e-mail message you are about to send:

  1. is subject to public disclosure under the Public Records Law
  2. is not private or confidential
  3. is retained for one month

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