Victim Impact Statement Template - Alberta printable pdf download

Victim Impact Statement

Your Name: ________________________________________________________

Offender's Name:____________________________________________________

Police Detachment: __________________________________________________

Police File Number: __________________________________________________

This form may be used to provide a description of the physical or emotional harm,

property damage or economic loss suffered by you as the result of the commission of

an offence, as well as a description of the impact of the offence on you. You may

attach additional pages if you need more space.

Your statement must not include

• any statement about the offence or the offender that is not relevant to the harm or loss

you suffered;

• any unproven allegations;

• any comments about any offence for which the offender was not convicted;

• any complaint about any individual, other than the offender, who was involved in the

investigation or prosecution of the offence; or

• except with the court’s approval, an opinion or recommendation about the sentence.

You may present a detailed account of the impact the offence has had on your life. The

following sections are examples of information you may wish to include in your

statement. You are not required to include all of this information.

Emotional impact

Describe how the offence has affected you emotionally. For example, think of

• your lifestyle and activities;

• your relationships with others such as your spouse, family and friends;

• your ability to work, attend school or study; and

• your feelings, emotions and reactions as they relate to the offence.

______________________________________________________________________

Physical impact

Describe how the offence has affected you physically. For example, think of

• ongoing physical pain, discomfort, illness, scarring, disfigurement or physical limitation;

• hospitalization or surgery you have had because of the offence;

• treatment, physiotherapy or medication you have been prescribed;

• the need for any further treatment or the expectation that you will receive further

treatment; and

• any permanent or long-term disability.

______________________________________________________________________

2015/07

VIC0016

Victim Impact Statement Template - Alberta