Form 112 - Victim Impact Statement And Request Page 2
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2c. Property damage is as follows:
___________________________________________________________________________________
___________________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________________________
Total cost to repair/replace property:___________ (Please attach bills, estimates)
Total amount covered by insurance: ___________ Name of insurance company:
______________________
What is your deductible? ____________ (Please attach copy of insurance policy showing deductible)
.
I wish to request restitution
d
For:
Medical Expenses
$_________________
(Restitution can only be
Counseling Expenses
$_________________
requested for UNINSURED
Property Damage or Loss
$_________________
expenses)
Vehicle Damage or Loss
$_________________
Other crime related expenses
$_________________
TOTAL EXPENSES:
$_________________
Amounts covered by insurance
$_________________
TOTAL RESTITUTION REQUESTED:
$_________________
e. I have recommendations for the outcome of the case. Here is my opinion and reasons:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________
____________________
Signature
Date
__________________________________________
____________________
Signature, if prepared by someone other than victim
Date
The purpose of this voluntary statement is to let the Court know how you feel about
the delinquent act and how it has affected you emotionally, physically and/or
financially.
The court will provide a copy of this form to the defense attorney if you choose to
complete it.
If you have any questions, please call ___________________________ at (802)______________ at
the ___________________ Court.
Please return this form to the _____________________ Court within two weeks of the date you
receive this letter.
7/10 SML
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