VICTIM IMPACT STATEMENT

VICTIM IMPACT STATEMENT
Filling out this form is voluntary. If you choose to fill out the form, you do not have to complete every section. You can fill in this form or you can write your statement in your own way using whatever method you feel most comfortable with.
Your name or name of the victim:
Name of Defendant:
Court Case Number
usually a 9 digit number
Physical Impact:

Please describe injuries you received, treatment you may have had, and ongoing physical effects. If you have additional information, such as a doctor report or photographs, you can email, mail or hand deliver them at the contact information listed below.
Type your response here
Emotional Impact:

Please describe psychological or emotional effects the crime has caused you. If you have additional information, such as reports from a psychologist or counselor, you can email, mail or hand deliver them at the contact information listed below.
Type your response here
Financial Impact:

Please describe loss of wages or income or other expenses incurred as a result of the crime. If you have additional information, such as pay stubs, email, mail or hand deliver them at the contact information listed below.
Type your response here
Property Damage / Property Loss:

Please describe to any of your property. You can describe any loss of property that has not been recovered. If you have additional information, email, mail or hand deliver them at the contact information listed below.
Type your response here
Other Relevant Information:

Please describe how your life has changed as a result of the crime. You can describe anything else you want to tell the Court that has not been included in other sections. If you have additional information, you can attach it to this form.
Type your response here
Sentence Input:

Please include what you would like the Court to order the Defendant to do, such as go to prison/jail, pay fines, pay restitution, have no contact with you, attend counseling, etc.
Type your response here
Print Name or Name of Person Filling out this Form:
Date:

Month Day Year
Uintah County Attorney’s Office
Victim Assistant Program
Attn: Marla Cox Victim Assistance Coordinator
641 East 300 South, Suite 200 Vernal, Utah 84078
Main: 435.781.5434 Cell: 435.630.1543
Should be Empty:

VICTIM IMPACT STATEMENT

Physical Impact:

Emotional Impact:

Financial Impact:

Property Damage / Property Loss:

Other Relevant Information:

Sentence Input: