Information That Should be Included in

Victim Impact Statements

(Last revised March 3, 2015)

Subject of Investigation/Defendant_____________________

Sentencing Date________________

Number_______________________

Various statutes allow and encourage written victim impact statements that describe the impact of crimes on the victims, their family, friends, community and society. Such statements should be used in arrest warrants, indictments and in pre-trial negotiations beginning as early as possible in the process. If there is a trial, information in these documents must be introduced as evidence at the trial in order for juries and courts to use this information in making findings of guilt and deciding sentences and appropriate restitution. The following outlines but does not limit specific information and the types of information that may be included .

Name of Person Completing Form ___________________________________

Relationship to Victim ____________________________________________

Name of Victim _________________________________________________

I. PHYSICAL INJURIES

A. Did the victim have any physical injuries as a result of this crime? (Check one) Yes_____ No_____

B. If yes, describe the physical injuries and any medical treatment the victim received. (Please add additional sheets, as necessary.)

II. PSYCHOLOGICAL EFFECTS AND TREATMENT

A. Describe any psychological effects of the crime (Please add additional sheets, as necessary.)

B. Describe any psychological treatment received or needed as a result of the crime (Please add additional sheets, as

necessary.)

III. LIFE CHANGES

Please describe any changes in your life as a result of this crime and any additional information you would like the court to consider about the impact this crime has had on your life, such as changes in personal welfare, lifestyle, or family relationships. (Please add additional sheets, as necessary.)

IV. ECONOMIC LOSS

A. Financial Loss

1. Property Loss. List the property lost as a result of this crime. This is property that has not been and is not expected to be recovered. (Attach any relevant receipts.)

2. Property Damage. (List property damage as a result of this crime and attach estimates/bills for repair.)

3. Medical/Hospital Costs, to include current or future costs

(Attach copies of bills.)                                                                                         Total$_________

4. Other Economic Losses/Costs — both current and future

(Lost wages and/or income — please specify type of loss)                                   Total$_________

Subtotal A: (Property Loss + Property Damage + Medical/Hospital + Other) =   Total$_________

B. Reimbursement Received

1. Property Insurance (Attach name and address of insurance company)         _______________

2. Hospital/Medical Insurance                                                                            _______________

3. Restitution Received                                                                                      _______________

4. Other Reimbursement(s)                                                                               _______________

Subtotal B (Sum of Reimbursements) =                                                            $______________

C. Economic Loss Not Reimbursed                                                                   $______________

(Subtotal A Minus Subtotal B)

______________________________________________   ____________________________________

Signature of Person Completing Form                                                                                     Date