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Victim Impact Statement

Call 765-641-9585

Victim Impact Statement

Victim Impact Statement

Your name:

Defendant Name:

Date:

Primary Phone:

Secondary Phone:

Other Phone:

Street Address:

City, State, Zip:

Email Address:

Close Friend or Relative Name:

Close Friend or Relative Phone:

Close Friend or Relative Address:

What is your relationship with Defendant?

New Field:

If yes, which court?

Your divorce attorney's name:

Please select any of the following emotion injuries that you have experienced as a result of this crime:

Loss of leep

Loss of appetite

Fear of being alone

Wanting to be alone

Cry more easily

Nightmares

Depression

Anxiety

Fear of strangers

Relationship problems

Lost trust in other people

Lack of concentration

Job / School stress

Anger

Other emotional injuries:

Have you or members of your family sought counseling as a result of this crime?

Yes

No

If you suffered physical injury, please mark the response that best describes your experience:

Treated at crime scene only

Treated at hospital and released

Hospitalized

If you were hospitalized, how long were you in the hospital?

When did you receive treatment? (approximate dates)

If injured, please describe the nature of your injuries:

Please summarize any financial losses that you've experienced as a result of this crime:

New Field:

New Field:

New Field:

Lost income:

Please attach itemized lists of stolen/destroyed items and their value:

New Field:

New Field:

New Field:

Amount covered by insurance to date:

Do you know the defendant to be in possession of a weapon?

Yes

No

I'm not sure

If you believe defendant is in possession of a weapon, please explain:

Is there anything else that you would like for the judge to take into consideration when determining the defendant's sentence:

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Learn about child support services we offer as well as information for employers.

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Law Enforcement Login

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Madison County Prosecutor

© Copyright 2022 Madison County Prosecutor's Office

VISIT

Madison County Courthouse

16 E. 9th St.

Anderson, IN 46016

CONTACT

765-641-9585

16 E. 9th St., Box 5

Anderson, IN 46016

All E-Service notifications should be sent to: mcprosecutor@madisoncounty.in.gov

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