Manitoba Victim Impact Statement Form (Page 4 of 4) in pdf

IMPORTANT:

When you submit your Victim Impact Statement to the Crown attorney, your

statement will be disclosed. This means a copy of your statement will be forwarded

to the offender and/or the offender’s lawyer.

The statements that I have made above are true to the best of my knowledge. I under-

stand that this information will be submitted to the offender or the offender’s lawyer and

may be submitted to the court if there is a sentencing hearing. I understand that I may be

called upon to testify in court if any information in this Victim Impact Statement is ques-

tioned. I also understand that if this statement is filed in open court, it becomes a public

document and discussions around the content of the statement may be presented and

recorded on the court record. I am submitting this statement voluntarily.

Signature of Victim: _______________________________ Date: __________________

Please complete the following if translation services were provided

in the preparation of this statement:

I did faithfully and to the best of my ability translate and interpret in the

___________________ language, the contents of this Victim Impact Statement

to the victim named herein, who indicated an understanding of the said contents.

Name: _____________________________Occupation: ________________________

Note: Community and Youth Correctional Services may use your Victim Impact Statement when writing Pre-Sentence

Reports, or for other case management purposes. Pre-Sentence Reports are used by the judge when deciding an appropriate

sentence for the offender.

Notice about personal information and personal health information.

The personal information and personal health information on this form is collected by Manitoba Justice, Prosecution

Services under the authority of the Criminal Code (Canada) and The Victims’ Bill of Rights of Manitoba.

It will be used and disclosed as stated on this form.

Your personal information and personal health information are protected by The Freedom of Information and Protection

of Privacy Act (FIPPA) of Manitoba and The Personal Health Information Act (PHIA) of Manitoba. We cannot use your

information for any other purpose without your consent, unless the law permits it or requires it. We cannot share your

information outside Manitoba Justice without your consent, unless the law permits or requires this.

If you have any questions or concerns about your Victim Impact

Statement, contact a Crime Victim Services Worker or a Crown attorney

at the number(s) provided on the Personal Information Sheet.

Manitoba Victim Impact Statement Form Page 4