Application For Restitution Assistance/form W-9 - Request For Taxpayer Identification Number And Certification
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4Monica J. Lindeen
Commissioner of Securities & Insurance
Montana State Auditor
840 Helena Ave. · Helena, MT 59601
Phone: 406.444.2040 or 800.332.6148
Fax: 406.444.5558 · Web:
Application for Restitution Assistance
Victim Name: ________________________________________________
Victim Address: ______________________________________________
City: _____________________ State: _____ Zip: __________
Phone Number: __________________
Case Name: ______________________
Case #: __________
Date Restitution Ordered: __________
Amount of Restitution Ordered: _____________
Less Restitution Received: _____________
Total Investment Loss: _____________
Instructions:
Attach a copy of the Final Order upon which this Application is based.
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Attach a copy of every restitution payment you received, if applicable. If noncash
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restitution was received, provide a complete description and value of the restitution.
Provide documentation that you were a resident of the state of Montana or were
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domiciled in Montana at the time of the securities transaction upon which your
restitution order was based.
Mont. Code Ann. § 30-10-1006 limits your claim to the lesser of $25,000 or 25% of the
amount of unpaid restitution awarded in a Final Order. When the Restitution Fund balance
approaches zero (<$ 1,000,000), a loss ratio (your total investment loss divided by your
total net worth) will be used to determine how much money you may be eligible to receive.
Complete the attached Net Worth Disclosure Form for the Department to calculate
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your loss ratio.
Complete the attached Form W-9 in order for the Department to issue you a check if
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the Application for Restitution Assistance is approved.
For further information, contact Lynne Egan, Deputy Securities Commissioner,
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(406)-444-4388.
Submit completed application materials to:
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Commissioner of Securities & Insurance
840 Helena Ave.
Helena, MT, 59601.
Page 1 of 4
Revised 06/12
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