Victim Impact Statement


This Victim Impact Statement is used by the Prosecutor for evaluating the effect the crime has had on you and your family. Without the information included in this form, you may not receive reimbursement and assistance that, by law, is yours. The Prosecutor and possibly the defendant and his/her attorney will receive a copy of this statement. If you need help completing this form, please call (928) 373-5060.

Print and fill out the Victim Impact Statement

*THE VICTIM IMPACT STATEMENT IS NOT CONFIDENTIAL.  THE PROSECUTOR AND POSSIBLY THE DEFENDANT AND HIS/HER ATTORNEY WILL RECEIVE A COPY OF THIS STATEMENT.

Defendant:

Case Number:

Charge:

Victim:

Address:

Home Address:

Home Phone:

Work Phone:

Best Time To Contact:

Alternate Contact:

Alternate Contact Phone Number:

1. What physical injuries did you or your family suffer? (List injuries such as broken bones, bruises, and scrapes (include injuries such as nausea, headaches, appetite changes, inability to sleep, etc.)

2. What psychological or emotional changes have occurred as a direct result of the crime? (List changes such as intense inability to concentrate, loss/gain in weight, inability to control emotions, etc.)

3. Please list any known previous arrests or criminal offenses committed by the Defendant and please note if the Defendant is currently on probation or parole for a criminal offense.

4. What recommendations do you have regarding sentencing, punishment, and/or treatment for the Defendant?

5. What specific concerns do you have about the defendant (Consider things such as: fear that thedefendant will try to contact or harass you; fear that the Defendant possesses firearms that they mayattempt to use against you, and alcohol/drug abuse by the defendant)?

6. Financial loss that was due to the charged criminal offense (Copies of all receipts or estimates mustbe attached to this form. Failure to provide proper documentation may result in failure to haverestitution ordered. Requests for restitution do not ensure that financial compensation is warranted.You may be asked to provide additional proof of loss and a restitution hearing may be ordered):

Property Loss

Description Of Loss:

Recovered / Repaired:

Purchase Price Or Current Value:

Date:

Repair Cost / Estimate:

Date:

Loss Covered By Insurance?:
No  Yes

Deductible (If Any)?:

Insurance CO. (name, address, number):

Policy Number:

Medical Expenses

Description Of Services:

Doctor/Hospital (Name & Number):

Total Expense:

Deductible:

Amount Paid By Insurance:

Insurance CO. (name, address, number):

Policy Number:

Loss Of Wages Due To Injuries Or Medical Treatment/Counseling:

Hours/Days Missed:

Hourly Wage/Salary:

** If Lost Wages Are Requested, You Must Provide A Copy Of Your Timeslip And A Letter From Your Employer Verifying Your Wages And Time Missed.