Victim Impact Statement

To be completed by victim or victim representative

Select County In Which The Crime Ocurred: Defendant's Name:

Please submit this form within 10 days. Failure to do so may result in your receiving no further hearing notifications or information regarding your case. Assistance in completing this form is available upon request.

Victim Information

First Name:

Middle Name:

Last Name:

Suffix:

Other Names (Maiden, Alias, Nickname):

Victim Representative:(Only if victim is a minor, business, deceased or incapacitated) Relationship to victim:

Mailing Address:

City:

State:

Zip Code:

Phone Number:

Alternate Phone Number:

Email Address

Financial Information (If Applicable)

Expenses (Proof Of Loss Will Be Required)

A scanned copy or photocopy of statements, invoices, estimates, insurance policy information, medical bills, etc. can be emailed to info@solicitor4.com for all proof of loss.

Medical $: Counseling $: Funeral $: Property Loss / Damage $: Insurance Deductible Amount $: Other $:

Recovered Amounts (If Applicable)

Victim Compensation (SOVA) $: Insurance Reimbursement $: Insurance Company, Mailing Address, & Phone Number:

Please read and answer YES or NO to the following questions:

I DO wish for this case to be DISMISSED. I do not wish to proceed with prosecution. I DO agree for the accused to receive Pre-Trial Intervention instead of going to court if possible. I DO wish to be notified of all court proceedings pertaining to this case. I DO wish to be notified of all post-conviction hearings, including appeals, probation, parole, release, or escape from prison, etc. I DO NOT wish to be notified of any court proceedings or post conviction hearings as listed above.

This portion of the Victim Impact Statement requests information about the effects of the crime. Please consider the following questions and respond only to those that apply to you and to this case.

Did you suffer any physical injuries?: Did these injuries cause any permanent or long-term disabilities or disfigurements?: Have you noticed any change in your lifestyle since this crime happened?: Did this crime affect you financially?: Have you received any counseling as a result of this crime?: Please use the space below for counseling requests and additional comments or information you would like us to know about this crime:

Confirm the following statements by selecting each box:

At any time, you feel threatened or you are harassed by the defendant, contact law enforcement immediately.

After completing and submitting your victim impact statement a confirmation email will be sent to the email address you provided above. Confirm the email address is correct before submitting and be sure to check your spam/junk folder.

If your address or phone number change you must notify the Fourth Circuit Solicitor's Office and provide your updated contact information.

A scanned copy or photocopy of statements, invoices, estimates, insurance policy information, medical bills, etc. can be emailed to info@solicitor4.com for all proof of loss. You must include the county or defendant name when submitting via email.

Thank you for taking the time to complete and submit your victim impact statement. This will help your voice be heard by the criminal justice system.

Signature (Typed):

Office of the Solicitor - Fourth Judicial Circuit

William B. Rogers, Jr.
Solicitor

Victim Impact Statement

To be completed by victim or victim representative

Victim Information

Financial Information (If Applicable)

Expenses (Proof Of Loss Will Be Required)

Recovered Amounts (If Applicable)

Please read and answer YES or NO to the following questions:

Confirm the following statements by selecting each box:

Thank you for taking the time to complete and submit your victim impact statement. This will help your voice be heard by the criminal justice system.

Office of the Solicitor - Fourth Judicial Circuit

William B. Rogers, Jr. Solicitor

Victim Impact Statement

To be completed by victim or victim representative

Victim Information

Financial Information (If Applicable)

Expenses (Proof Of Loss Will Be Required)

Recovered Amounts (If Applicable)

Please read and answer YES or NO to the following questions:

Confirm the following statements by selecting each box:

Thank you for taking the time to complete and submit your victim impact statement. This will help your voice be heard by the criminal justice system.

William B. Rogers, Jr.
Solicitor