PLEASE FOLLOW THESE DIRECTIONS
WHEN COMPLETING YOUR
LEO VICTIM IMPACT STATEMENT

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

BREVARD COUNTY LAW ENFORCEMENT:

  • You may fax the form to: 321-617-7556
  • You may courier in Brevard to: VWS/State Attorney's Office - #84

SEMINOLE COUNTY LAW ENFORCEMENT:

  • You may fax the form to: 407-665-6004
  • You may courier in Seminole to: VWS/State Attorney's Office Justice Center - 2nd Floor

LAW ENFORCEMENT - VICTIM IMPACT STATEMENT

* are Required

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

VICTIM CONTACT INFORMATION

PHONE#:
*Home:
*Work:
*Cell:
*Email:

VICTIM COMMENTS

How has the crime affected you as a law enforcement officer?
What (if any) hardships have you experienced as a result of this crime?


PHYSICAL INJURIES/DAMAGES

Did you receive any injuries as a result of the crime?          
If so, were injuries covered by Workman's Compensation?
Please give a brief summary about your injuries.

Was anything stolen or damaged as a result of this crime?
If so, please give a brief summary.


VWS ASSISTANCE /COURT ATTENDANCE REQUEST

Please select what Victim Witness Services can provide you.

Court Case Information: Supportive Services:
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.):

Law Enforcement Officer:
Badge #:
Date:

 
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