Victim Impact Information Form

Victim Impact Information Form
Prosecutors file # (found on cover letter) Defendants Name: _______________________
Your Name: If you are not the victim, how are you related to the victim? __________
This Victim Impact Information Form and Victim Impact Statement are ways for you to participate in the prosecution and sentencing of the offender. Instructions: Please answer the questions that apply to your situation. If you need more space, you may use additional sheets of paper. Please print neatly or type.
(1) If you were hurt during the incident, please describe your injuries _____________________________________ _____________________________________________________________________________________________ ___________________________________________________________________________________________
(2)

Did you need medical treatment or mental health services because of the incident?_____________________

3. (3)  Do you have medical insurance that will help you with the cost?...................................................Yes or No If you, how much will or did you have to pay of your own money? $ ______________________
   How much has your insurance paid so far? $ _________________________________________
   
4. (4)  Did you have property damaged or stolen in this incident ?............................................................Yes or No Please list all items damaged or stolen and the cost of the item:
   

Item __________________________
______________________________
______________________________

Date of Purchase ______________
______________ ______________

Purchase Price ____________
____________ ____________

Current Value _____________
_____________ _____________

5. (5)  Do you have property insurance that will help with the cost ?.........................................................Yes or No
   If yes, how much will or did you have to pay of your own money? $
   
6. (6)  Have you missed work or school because of the incident ?..............................................................Yes or No If yes how many days have you missed? Please give the dates: ..............................
   

Did you lose pay because of the time you missed? How much? .............................

7. (7)  Do you need help in filing a claim with the Victims of Crime Compensation Board for assistance with the cost
   of medical services, counseling, funeral expenses or lost wages?....................................................... Yes or No
   
8. (8)  Do you want the judge to order restitution? YES OR NO If yes, how much? ...................................... Restitution is money that the offender must pay back to you because of the crime. You have the right to ask for a restitution order.
   In order for the judge to order restitution, you must attach copies of bills, receipts or estimates of medical cost, counseling expenses, stolen or damaged property and lost wages. If you do not know these expenses yet,
   please send in the form now and the expenses as soon as you get them.
   
9. (9)  Do you need interpreting services or other special assistance to help you give a statement or testify? If yes, what type of assistance? Please be specific: ......................................
   

(10) Would you like help finding a counselor or support group for crime victims? .........................
IMPORTANT: Court rules require the Prosecutors office to give a copy of this form to the defendant. The above statements are true: Please sign: Date:

VICTIM IMPACT STATEMENT
Prosecutors File #: Defendants Name:______________________ Your Name: Indictment#:__________________________
In the space below, please write about how you and your family were affected by this incident. Please do not talk about the facts of the case or anything you might think of as testimony. The judge and the prosecutor would like to know:

a. b. c.

Your feelings about the incident
How your life is different because of the incident

What you think the defendant’s sentence should be ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________