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Case Information

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Case Information

State v.

Case Number

A Victim Impact Statement is used to describe how the crime has impacted you. You are encouraged to include any information you feel is relevant to your experience. The following prompts may be used as a guide:

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The nature and extent of any physical injury, emotional trauma, or psychological distress suffered.

The nature and extent of any physical injury, emotional trauma, or psychological distress suffered.

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An explanation of economic losses, including injury or damage and their associated costs, if any.

An explanation of economic losses, including injury or damage and their associated costs, if any.

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The amount of restitution being requested and/or relief that has been or will be sought from other sources.

The amount of restitution being requested and/or relief that has been or will be sought from other sources.

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Other statements or comments.

Other statements or comments.

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By signing below, I certify all information given in this form is true and complete.

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By signing below, I certify all information given in this form is true and complete.

Name:

Date:

I am completing this on behalf of a victim who is under age 18, disabled or incapacitated.

Victim's Name:

Relationship

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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