VICTIM COMPENSATION

(MONTH) 20____

DATE	CASE #	NAME	AMOUNT

TOTAL

REMITTED BY: CITY OF (CITY)

MUNICIPAL COURT

(ADDRESS)

(CITY, STATE ZIP)

DIVISION OF VICTIM SERVICES	777-6271

2301 CENTRAL AVENUE

BARRETT BUILDING 4TH FLOOR

CHEYENNE, WY 82002