PLEASE FOLLOW THESE DIRECTIONS WHEN COMPLETING YOUR INDIVIDUAL VICTIM IMPACT STATEMENT

  1. Please use the information contained in the letter to complete the Defendant's Name and the Case Number on the form. This information is located just under your name and address on the letter.
  2. Please complete as much information as possible on the form.
  3. After completed, please print a copy for your records.
  4. 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 .
  5. By clicking the SUBMIT button, you automatically forward the form to the Victim Witness Service's email address. (VWS@sa18.org)

If the crime occurred in BREVARD COUNTY:

  • 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 32940-6605
  • You may fax the form with attachments to: (321)617-7556
  • You may courier the form to: VWS/State Attroney's Office - #84
  • You may email the information with attachments to: VWS@sa18.org

If the crime occured in SEMINOLE COUNTY:

  • You may mail the form w/attachments to:
    Office of the State Attorney Victim Witness Services
    101 Bush Boulevard
    Sanford, FL 32773-8006
  • You may fax the form with attachments to: (407)665-6004
  • You may courier in Seminole to: VWS/State Attorney's Office Justice Center - 2nd Floor
  • You may email the information with attachments to: VWS@sa18.org

INDIVIDUAL - VICTIM IMPACT STATEMENT

* are Required
* State of Florida vs:
County where the crime occured * County of
case number: followed by (MMA), (CFA), or (CJA) Court Case Number:

VICTIM CONTACT INFORMATION

Victim Name:
Victim Address:
* Victim Home Phone:
* Victim Work Phone:
* Victim Cell Phone:
* Email Address:

VICTIM COMMENTS

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

PHYSICAL INJURIES

Have you recieved medical treatment as a result of this crime?
If you received medical treatment as a result of this crime, complete the following
Name of Doctor:
Phone:
Fax:
Hospital or Clinic:
Address:
Doctors Email Address:
Type of Injuries:
Total cost of medical treatment to date:
Have you applied for Crimes Compensation?
Have you received monies from Crimes Compensation?
Amount:
Claim #:
Analyst Name:

PROPERTY OR MERCHANDISE/ STOLEN OR DAMAGED

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

If necessary, use additional sheet(s) and list the below information for each item.

Item 1

Damaged:

Stolen:

Purchase Date:

Purchase Price:

Condition:

Fair Market Value (at time of crime):

Cost to Repair (if applicable):

Item 2

Damaged:

Stolen:

Purchase Date:

Purchase Price:

Condition:

Fair Market Value (at time of crime):

Cost to Repair (if applicable):

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.
Do you have insurance to cover your losses?
Type of Insurance to cover your loss:
Health:
Property:
Auto:
Other:
Name of Insurance Company:
Phone:

Insurance Company(s) Address:

Insurance Company Email:
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.
Court Case Information:
Property Return:
Supportive Services:
Home 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
Victim Name Parent/Guardian name if victim is a minor
Date:
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