Ohio Victims Rights Request/Waiver Form (Confidential)

Form Use:

Initial ContactVictim Initiated Change

Victim did not elect or was unable to complete the form

YesNo

Form completed by:

Law EnforcementVictimProsecutor

Reporting Agency: *

Dublin Police Department - 6565 Commerce Pkwy Dublin, OH 43017

Reporting Officer/Investigator/Detective: *

Reporting Agency Phone:

Please enter a valid phone number. Dublin Police (614) 889-1112

Crime Committed/Charge(s):

Report Number:*

CFS if there is not a report number

County*

Defendant/Suspect's Name:

If known

Arraignment

Date, Time and Location if known

Automatic Rights—You Do Not Need to Request These Rights

The right to be informed of your rights.
The right to be treated with fairness and respect for your safety, dignity and privacy.
The right to reasonable protection from the accused or any person acting on behalf of the accused.
The right to information about the status of the case.
The right to refuse a defense interview, deposition, or other discovery request.
The right to object to defense requests for access to your confidential information, including medical, counseling, school or employment records, access to your personal devices or on-line accounts, or other personal information.
The right to be present at all public proceedings.
The right to have a support person with you during proceedings.
The right to tell the court your opinion in public proceedings involving release, plea, sentencing, disposition, parole, and any other hearing that involves victims’ rights.
The right to object to unreasonable delays.
The right to full and timely restitution from the offender.

Rights That Must Be Requested

I WANT my name, address, and identifying information to be redacted (removed) from:

Law enforcement recordsProsecutor recordsCourt records

I WANT notice of the arrest, escape, or release of the offender.

YesNo

I WANT reasonable and timely notice of all public proceedings.

YesNo

I WANT to be notified of subpoenas, motions or other requests to access any of my personal information.

YesNo

I WANT to appoint a Victim’s Representative. You will be asked to provide the information below.

YesNo

I WANT to confer with the prosecutor at certain points in the case, including before pretrial diversion is granted, before the prosecutor amends or dismisses an indictment, information, or complaint, before the prosecutor agrees to a negotiated plea, and before a trial or adjudicatory hearing

YesNo

Please specify if you would like a foreign language interpreter and if so, in what language, or if you would like an American Sign Language interpreter.

Law Enforcement/Prosecutor Use Only

Victim of violation of protection order, offense of violence, or sexually oriented offense was presented the form, but the victim was unable to complete the form. Victim is opted in to all rights until the victim completes the form or is contacted by the prosecutor and provided the opportunity to complete the form. The public records division and custodial agency was provided the victim’s and/or victim representative’s information for redaction and notification.

Victim Name:*

Ohio Victims' Rights Request form provided to me by

Law enforcement officerProsecutor's office

Date the form was provided:

Date

Victim Representative Name:

Complete by the Victim or Law Enforcement Official

Email:*

example@example.com

Phone Number:*

Please enter a valid phone number.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred method of contact (check all that apply):

EmailPhone CallMail

Please provide my name and contact information, and that of my representative, if applicable, to the custodial agency, if any.

YesNo

Email:

example@example.com

Phone Number:

Please enter a valid phone number.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

As the victim, I do not wish to receive notices about this case. Please provide notices to my representative.

YesNo

For Business Victim Use Only

As the representative of the business below, by checking this box, I hereby OPT OUT of the business’s victims’ rights in this case and future cases unless I notify law enforcement, the prosecutor, or the court otherwise.

YesNo

What Business Do You Represent:

Victim's Signature:*