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All Victims - Victim Impact Statement

Name:		Case Number:
Full Address:		State V.
Phone (Home):		Case Coordinator:
Phone (Work):
I. Property Stolen or Damaged

1. What property was stolen or damaged as a result of this crime?

2. What was the total value of the stolen or damaged property? (Please attach bills, receipts, cancelled checks, estimates)
3. What was the cost of replacement or repairs? (Please attach bills, receipts, cancelled checks, estimates)
4. Do you have insurance that paid for the stolen or damaged property? If so, please list the amounts received and give the name and address of your insurance company and agent.
II. Physical Injury

1. If you suffered any physical injury or disability as a result of this crime, please describ your injuries.

2. If you were hospitalized because of your injuries, please give the name of the hospital, attending physician, and the length of your hospital stay.
3. If you received outpatient treatment for your injuries, please give the name of the physician or hopsital and duration and type of treatment.
4. What were your total medical expenses? (Please attach bills, receipts, cancelled checks, estimates)
5. Do you have medical insurance that paid for your medical treatment and hospitalization? If so, please list the amounts received and give the name and address of insurance company and agent.
6. If your injuries caused you to miss time from work, please indicate how much time you missed and how much money was lost in wages. Also, please give the name, address and telephone number of your employer.
7. If you received sick leave pay for the days you missed from work, please indicate total number of days and total amount of sick pay received.
8. If you expect to have any future medical expenses (outpatient therapy, prescription drugs, etc.), please describe those expenses and state whether your insurance will pay for them.
III. Emotional Injury

1. Were you psychologically injured? If so, please describe the emotional impact this crime has had upon you and your family and any resulting changes that have occurred.

2. As a result of this crime, have you or your family received any counseling or therapy? (Please attach bills, receipts, cancelled checks, estimates)

3. Please describe any other effects that being a victim of a crime has had upon you or your family.

All Victims - Victim Impact Statement

I. Property Stolen or Damaged

II. Physical Injury

III. Emotional Injury