Welcome To The State Attorney’s Office, 18th Judicial Circuit:

PLEASE FOLLOW THESE DIRECTIONS WHEN COMPLETING YOUR 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: