PLEASE FOLLOW THESE DIRECTIONS
WHEN COMPLETING YOUR
BUSINESS VICTIM IMPACT STATEMENT

  • Please use the information contained in the letter to complete the Defendant's Name and the Case Numberon the form. This information is located just under your name and address on the letter.
  • Please complete as much information as possible on the form.
  • After completed, please print a copy for your records.
  • By clicking the SUBMIT button, you automatically forward the form to the Victim Witness Service's email address.
  • If you have receipts, estimates, or any other additional information pertaining to your losses, please print the COMPLETED form, attach copies and either mail or fax. DO NOT SEND ORIGINALS.

BREVARD COUNTY BUSINESSES:

  • You may mail the form w/attachments to:
    Office of the State Attorney Victim Witness Services
    2725 Judge Fran Jamieson Way
    Building D
    Viera, Florida 32940
  • You may fax the form with attachments to: 321-617-7556

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SEMINOLE COUNTY BUSINESSES:

  • You may mail the form w/attachments to:
    Office of the State Attorney Victim Witness Services
    101 Bush Boulevard
    Sanford, FL 32773
  • You may fax the form with attachments to: 407-665-6004

BUSINESS - VICTIM IMPACT STATEMENT

* are required

*State of Florida vs:
Court Case Number: case number - followed by (MMA), (CFA), or (CJA)
Brevard Case Seminole Case

Business Address:
*Business Phone: Business Fax:
*Business Email: *Home Phone: *Cell Phone:
 

VICTIM COMMENTS

How has the crime affected you, and your business?
What (if any) hardships have you, and your business/employees experienced as a result of this crime?:


PROPERTY OR MERCHANDISE/ STOLEN OR DAMAGED

If you had any property stolen or damaged list each item(s) below.

Are there any other expenses as a result of this crime not reimbursed? If yes, please describe:

Are any items currently in the custody of a law enforcement agency? If yes, please list the items:

Total amount of expenses incurred for stolen or damaged property:

INSURANCE INFORMATION

If you had property loss, damages or physical injuries as a result of this crime, please complete the following.
Type of Insurance to cover your loss:
Health: Property:
Auto: Other:
Name of Insurance Company:
Phone:
Insurance Company(s) Address:

Deductible: $ Claim #:
Award (if any): $
If no claim was filed, please explain:


VWS ASSISTANCE /COURT ATTENDANCE REQUEST

Please select what Victim Witness Services can provide you.

Case Information: Property Return: Supportive Services:
Business Security: Victim Compensation:
I wish to attend all court proceedings:
I wish to attend necessary court proceedings:
I do not wish to attend any court proceedings (other than my legal requirements.):

I hereby swear or affirm that the above statement is true and correct
Business Representative/Employee Completing Form: Date:

 
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