VIS online Form

Victim Impact Statement Form
This statement is used to assist the prosecutor and court in their effort to weigh all factors and to impose a fair sentence. Your cooperation is appreciated.

YOUR PERSONAL CONTACT INFORMATION. Note this contact information will not be disclosed to the defendant:
Do you want to opt in to receive Victims' Rights?*

YesNo * Please note that by opting out of Victims' Rights you will no longer receive future notifications of case progress. You can opt back in at any time.
Name*

First NameLast Name
Case Number *
Proceeding Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone number

Area CodePhone Number
Email
example@example.com
Notification Preference:

EmailStandard Mail
History
Was the defendant known to you before this incident occurred?
If "Yes", please indicate your relationship:
If there is a history of this type of behavior, please list the incidents, the city where it occurred, and the approximate dates and if reported to police:
Physical Impact
What, if any physical injury or disability have you suffered as a result of this incident?
Explain any medical treatment received, as well as any recurring implications:
Emotional Impact
What was the emotional impact of this incident on you? How did it affect your life?
Sentencing
What do you feel would be a fair sentence in this case?

Fine.Jail.Probation.Attend a Domestic Violence or Anger Management counseling program.Attend a drug/alcohol counseling program.Defendant be required not to threaten, harm, or harass the victim.Defendant be required not to go near the victim's home.Defendant be required not to go near the victim's school.Defendant be required not to go near the victim's work.Pay restitution. (I understand that it is my responsibility to provide written documentation showing my out of pocket expenses. These can be emailed, mailed, faxed, or hand delivered to the prosecutors office).Other
Other suggestions:
Restitution
How has this crime affected your ability to earn a living? Please explain the extent of your economic loss, the need for restitution, whether or not you have already received compensation.
Disclaimer*

I acknowledge that pursuant to A.R.S. § 13-4430, any and all victim communication shared with the Glendale City Prosecutor's Office, including its victim assistance caseworkers, may be disclosed to its employees and volunteers, including victim advocates, prosecutors and support staff. In addition, any exculpatory evidence gathered through said communications must be disclosed to the listed defendant or, if applicable, defense counsel.I certify that I am the person named above or have permission from the person named above to submit information on their behalf and the information provided is true and accurate.
Should be Empty:

Victim Impact Statement Form

History

Physical Impact

Emotional Impact

Sentencing

Restitution