Manitoba Victim Impact Statement Form printable pdf download

Manitoba Victim Impact Statement Form

When completed please forward to the Crown attorney’s office.

Name of victim: _________________________________________________________________

Police Incident Number: ___________________________________________________________

Date of offence: _________________________________________________________________

Police agency the incident was reported to: __________________________________________

Charges (if known): ______________________________________________________________

Name of offender (if known): ______________________________________________________

Town, city or community where the incident occurred: _________________________________

Relationship to the offender (if any): ________________________________________________

You can ask to read your statement in court. If you would like to do so, please check the

following box:

I wish to read my statement aloud in court.

Please Note: The court will be informed if you wish to read your Victim Impact Statement in court; however, if you are not present at the

hearing, sentencing will proceed.

If you are not the direct victim, please indicate why you have completed

this statement and your relationship to the victim.

Name: _________________________________________________________________________

Relationship to the victim: _________________________________________________________

Reason: _________________________________________________________________________

________________________________________________________________________________

Ces renseignements sont également offerts en français.

Manitoba Victim Impact Statement Form