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

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

LEO - VICTIM IMPACT STATEMENT

* are Required
* State of Florida vs.
 
case number: followed by (MMA), (CFA), or (CJA) Court Case Number:
 
Law Enforcement Agency:
 

VICTIM CONTACT INFORMATION

* Home Phone:
 
* Work Phone:
 
* Cell Phone:
 
* 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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