The Victim Impact Statement - HELPFUL FOUNDATION

VICTIM IMPACT STATEMENT *

Victims have the right to submit a Victim Impact Statement. The Victim Impact Statement is a written, detailed account of the emotional, physical, psychological, and financial impact the crime hashed on the victims and family members. This document can be used to explain your feelings of loss, frustration, and fear. Only you can provide this vital information. The Victim Impact Statement has become a significant tool in the criminal justice process.

VICTIM IMPACT INFORMATION *

To be completed by the victim, parent/guardian or close relative of the victim. Please give any other information you believe is important about the effect of this crime on you and your family. Please do not relate any information about the crime itself; those facts are available already in other reports.

Victim Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Date

EMOTIONAL/PSYCHOLOGICAL IMPACT. *

Use this section to discuss your feelings about what has happened to you as a result of the crime and how it has affected your general well-being. Please check

Please check all the reactions you have experienced.

PHYSICAL INJURY.

Use this section to discuss what physical injuries or symptoms were suffered as a result of this crime. You may want to write about the extent of the injuries, how long your injuries lasted, and if you received and/or where you received medical treatment for your injuries.

Indicate medical treatment received. Attach a doctor’s statement if you wish.

Treated at the scene only
Treated at medical center

Hospitalized for days

VICTIM IMPACT STATEMENT *

VICTIM IMPACT INFORMATION. To be completed by the victim, parent/guardian or close relative of the victim. Please give any other information you believe is important about the effect of this crime on you and your family. Please do not relate any information about the crime itself; those facts are available already in other reports

Request for appropriate action

To be completed by the victim, parent/guardian or close relative of the victim.

Incident Information / Date or Time

Date

Time

Location of Incident

Brief Description of Incident *

Information submitted by:

Victims
Parent/Guardian
Close Relative
others

Name *

First

Last

DECLARATION

I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. In case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences. I also declare that if any information provided by me is found false, my candidature may be rejected at any point in time. I/ We have not concealed or misrepresented any fact stated in aforesaid columns and the documents submitted herewith.