Form 112 - Victim Impact Statement And Request

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Form 112
Victim Impact Statement and Request Form
Re: docket #: ________________________________
Your Name: _________________________________ Date of Offense: ____________________
1. If the judge determines that the child has committed the delinquent act in question, the court may
release the identity of the child to you if the court finds that release of the child’s identity is in the
best interests of both you and the child.
( ) I REQUEST that the court tell me the identity of the juvenile for the following reasons:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2. The victim of a delinquent act has the right to file with the court a written or recorded statement of
the impact of the act on the victim and the need for restitution.
( ) I enclose this form as my written statement of the impact of the delinquent act on me.
( ) I will send the court a separate written or recorded statement of the impact of the delinquent act on me
and the need for restitution.
( ) I REQUEST to be present at the disposition (“sentencing”) hearing to tell the court how the offense has
affected me. The reasons for this request are as follows:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3. The court will take a victim’s views into consideration in deciding the outcome (“disposition”) of
the case. If you wish, you may use this form to describe the impact that this incident has had on you
as the victim, including any physical injuries, emotional impact, and physical damage.
a. Physical injuries requiring medical treatment? YES _______
NO_______
If yes, please describe
your injuries and treatment:
________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you have insurance that will cover costs of medical treatment?
YES_____ NO____
Name of insurance company_____________________________
Will there be any uninsured expenses related to medical treatment? YES_____ NO____ UNSURE____
b. The emotional or psychological impact is:
_________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I will / will not be seeking counseling as a result of this incident.
I do / do not
have insurance that will cover the costs of counseling.

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