VICTIM'S RIGHTS REQUEST/WAIVER FORM

VICTIM'S RIGHTS REQUEST/WAIVER FORM

City of Lebanon, Division of Police | 25 W Silver St, Lebanon, OH 45036 |513-932-2010
Pursuant to Ohio Constitution Article I, § 10a, I assert or waive the rights checked below. I understand that if I change my mind, I must complete a new form and return it to the investigating officer, or, if the suspect has been charged, to the prosecutor. The investigating officer will provide the prosecutor’s contact information.
Initial ContactVictim Initiated Change
Case Report No.
Officer & Badge No.
RequestWaive
RequestWaive
RequestWaive
RequestWaive
RequestWaive
RequestWaive
RequestWaive
Representative Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Representative's Relationship to Victim:
RequestWaive
RequestWaive
If you are denied your rights you may seek to enforce your rights on your own, ask the prosecutor to enforce your rights, or retain an attorney. You may request free legal assistance through nonprofit organizations such as Ohio Crime Victim Justice Center at OCVJC.org, (866) 665-3330, or info@ocvjc.org.
Victim's Name:

First NameLast Name
Date:

MonthDayYear
Victim's Email:
example@example.com
Victim's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Victim's Signature:

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Officer/Agency Representative Name:

First NameLast Name
Date:

MonthDayYear
Officer/Agency Representative Signature:

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Should be Empty: