Crime Victim Notification Request And Demand For Rights Form Page 2
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3CRIME VICTIM NOTIFICATION REQUEST AND DEMAND FOR RIGHTS FORM
Form must be completed for each defendant and/or juvenile.
In the Circuit/Juvenile Court for
County/City (Circle one)
Court Case No.
Case Tracking No. (If known)
Inmate No. (If known)
State v.
Date of Birth
_________ /_________ /________
CRIME VICTIM NOTIFICATION REQUEST AND DEMAND FOR RIGHTS FORM
(PLEASE BEAR DOWN FIRMLY AND PRINT OR TYPE ALL INFORMATION)
Victim’s Name:
If a minor, Date of Birth
Ms. / Miss / Mrs. / Mr. (Circle one)
_________ /_________ /______
If Victim is a Minor, Deceased, or Disabled,
Relationship
give Victim Representative’s Name:
Ms. / Miss / Mrs. / Mr. (Circle one)
I REQUEST NOTICE OF ALL EVENTS RELATED TO THIS CASE AND TO THE DEFENDANT/JUVENILE, AS
ALLOWED BY LAW, AND DEMAND ALL THE RIGHTS TO WHICH VICTIMS OF CRIME ARE ENTITLED.
I UNDERSTAND THAT IF I DO NOT COMPLETE THIS FORM AND RETURN IT TO THE STATE’S
ATTORNEY’S OFFICE THAT I MAY NOT BENEFIT FROM MY RIGHTS AS A VICTIM.
Signature of Victim or Victim’s Representative
Date
Please refer to the instruction page attached to the front of this form for specific instructions and information.
PLEASE PROVIDE AN ADDRESS AND PHONE NUMBERS TO RECEIVE ALL NOTICES.
THIS FORM WILL BECOME PART OF THE PUBLIC RECORD IN THIS CASE. IF YOU DO NOT WANT YOUR ADDRESS AND
PHONE NUMBER IN THE RECORD, PROVIDE AN ALTERNATE VICTIM CONTACT NAME, ADDRESS AND PHONE NUMBER
Victim/Victim’s Representative:
Address
City
State
Zip
Phone (Day)
Phone (Evening)
Cell Phone
Email
If another person or organization has agreed to receive and forward notices to you AND you
agree to maintain contact with the Alternate, complete the following information
Name of Alternate Victim Contact:
Relationship to Victim/Victim’s Representative:
Family Member
Friend
Support Agency
other
Contact Address
City
State
Zip
Phone (Day)
Phone (Evening)
Cell Phone
Email
Criminal Justice Agencies please refer to the reverse side of this form for processing instructions.
WHITE: Clerk of Court; YELLOW: State’ s Attorney; PINK: Detention/DOC/DHMH; GREEN: Parole & Probation;
BLUE: Attorney General’ s Office; GOLDENROD: Victim/Victim’ s Rep.
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