Fillable Printable Victim Impact Statement Sample Form
Fillable Printable Victim Impact Statement Sample Form
Victim Impact Statement Sample Form
UNITED STATES v. ______________
COURT DOCKET NUMBER _____________________
VICTIM NAME:
INDIVIDUAL VICTIM IMPACT STATEMENT/FINANCIAL CRIME
How have you and members of your family been affected by this crime?
Ple a se c ontinue this statement on an additional sheet of paper if you wish.
Have you or members of your family received counseling as a result of this crime? Please
explain.
Have you filed a civil suit against the defendant? If yes, please list the case name, court location,
and docket number.
Page 2
VICTIM IMPACT STATEMENT/FINANCIAL CRIME
Do you relate to people differently since the crime? Please explain.
How has the crimes affected you and your family's lifestyle? Please explain.
Has the crime affected your family's livelihood? Please explain.
Have you experienced any of the following reactions to the crime:
PLEASE REALI ZE THESE ARE NORMAL REACT I ONS TO A TRAUMATIC EVENT OR SIT UATI ON.
Anger Anxiety Fear Grie f Guilt Numb Chronic Fatigue
Sleep Loss Nightmares A ppet i te C han ge Unsafe Uncontrolled Crying
Trouble Concentrating Repeated Memory of Crime Depression
Please describe any other reactions to the crime committed.
Do you feel the defendant is or will be a threat to you, your family or the community?
Yes No, Please explain.
Page 3
VICTIM IMPACT STATEMENT /FINANCIAL CRIME
What else would you like the Judge to know about the defendant, or your situation as a result of
the crime?
If a victim consents, the Court may also make restitution in services in lieu of money, or make
restitution to a person or organization designated by a victim. If you are interested in this option,
please explain.
1. Please list your actual financial losses from this crime. List only those items for which you
have not been or do not expect to be repaid. Please attach receipts or other reco rds when ev er
possible. (Use additional paper if needed.) Please differentiate any monies already repaid by a
defendant.
2. Have you been assessed any additional taxes, penalties or interest by the federal government
as a result of this case? If yes, please explain.
3. Have you or anyone on your behalf initiated civil action against any party as a result of this
offense? If yes, please state the case name, docket number and court of jurisdiction.
Page 4
VICTIM IMPACT STATEMENT /FINANCIAL CRIME
4. If you have suffered any other expenses as a result of this crime, please list them below.
Include such items as counseling, medical bills, lost income and necessary child care,
transportation, and other expenses related to participation in the investigation or prosecution of
the offense or attendance at proceedings related to the offense. Please be specific and at t ach
copies of receipts if possible.
Signature:
Printed Name:
Date:
CONFIDENTIAL
United States v.
Case Number:
The address and telephone contact information provided below will only be provided to the
presentence probation officer, and the United States Attorney's Office, unless a court order
signed by the Judge authorizes the release of this page to the Court and attorney for the
defendant.
Printed Name:
Signature:
Address:
Phone: (hm) (wk)
Fax: E-Mail:
