PLEASE FOLLOW THESE DIRECTIONS WHEN COMPLETING YOUR LEO 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

LEO - 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:
The advocate's name who is assigned to this case Advocate Name:

VICTIM CONTACT INFORMATION

Name:
Badge #:
Agency:
* Work Phone:
* Personal 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

Type of Injuries:
Did you recieve medical treatment as a result of these injuries?
If you received medical treatment as a result of this crime, complete the following
Total cost of medical treatment to date:
were injuries covered by Workman's Compensation?
Claim #:
Analyst Name:

PROPERTY OR MERCHANDISE/ STOLEN OR DAMAGED

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

Item 1
Damaged:
Yes No
Stolen:
Yes No
Purchase Date:
Purchase Price:
Condition:
Fair Market Value (at time of crime):
Cost to Repair (if applicable):
Returned or in Police Custody?

Total amount of expenses incurred for stolen or damaged property:

VWS ASSISTANCE

Please select what Victim Witness Services can provide you.
Court Case Information:
Supportive Services:

COURT ATTENDANCE REQUEST

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
Law Enforcement Officer/Victim Signature and Badge Number
Date:
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