CRIME VICTIM INFORMATION SHEET A

VICTIM IMPACT CONTACT INFORMATION

CONFIDENTIAL INFORMATION SHEET

OFFENSE INFORMATION. To be completed by the Victim Assistance Coordinator.

Offense:

Offense date:

Defendant:

(Last Name)

(First Name)

(MI)

(DOB)

Cause/Case #:

CID #:

Court #:

County of offense:

County of conviction/adjudication:

TDCJ #:

SID #:

The Confidential Information Sheet will be used by criminal justice professionals to contact you throughout the process. SECTIONS 1 & 2.
To be completed by the victim, parent/guardian or close relative of the victim.

SECTION 1. NOTIFICATION.

Do you want to be notified of relevant court proceedings?

o YES

o NO

If the defendant is placed on community supervision (probation), do you want to be notified of relevant community supervision proceedings?

o YES

o NO

If the defendant is incarcerated in a Texas Department of Criminal Justice facility, do you want to be notified if he/she is being considered for parole or release?

o YES

o NO

If the defendant is incarcerated in a Texas Department of Criminal Justice facility, do you want communications with the offender restricted?

o YES

o NO

IF YOU MOVE OR CHANGE ANY OF YOUR CONTACT INFORMATION, CALL YOUR VICTIM ASSISTANCE COORDINATOR OR THE TEXAS DEPARTMENT OF CRIMINAL JUSTICE-VICTIM SERVICES DIVISION AT 800-848-4284.

SECTION 2. CONFIDENTIAL INFORMATION

Victim’s Name:

Driver’s License and State:

Date of Birth:

o Male

o Female

Person Submitting this Statement:

Relationship to Victim:

Address:

Date of Birth:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell:

Email Address:

Driver’s License and State:

Please provide the contact information of someone who will always know how to reach you.

Full Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell:

Email Address:

Signature:

Date:

VIS (Rev 9/2009)

VICTIM IMPACT STATEMENT

RETURN THIS DOCUMENT TO YOUR VICTIM ASSISTANCE COORDINATOR

OFFENSE INFORMATION. To be completed by the Victim Assistance Coordinator.

Offense:

Offense date:

Defendant:

(Last Name)

(First Name)

(MI)

(DOB)

Co-Defendant:

(Last Name)

(First Name)

(MI)

(DOB)

Cause/Case #:

CID #:

Court #:

County of offense:

County of conviction/adjudication:

TDCJ #:

SID #:

Victim Assistance Coordinator:

Rec’d:

Agency:

Address:

Phone:

E-mail:

VICTIM IMPACT INFORMATION. To be completed by the victim, parent/guardian or close relative of the victim. Please give any other information you believe is important about the effect of this crime on you and your family. Please do not relate any information about the crime itself; those facts are available already in other reports.

Victim’s Name:

The information in this statement will show the impact the crime has on the victim, the parents, guardians or close relative of the victim or other family members of the victim. It may be used at each phase of the criminal justice process: from the prosecution of the offense; to incarceration in the Texas Department of Criminal Justice; and through the parole review process. Please answer only as many questions as you wish. If you need more space, feel free to use additional sheets of paper and attach them to this Victim Impact Statement.

EMOTIONAL/PSYCHOLOGICAL IMPACT. Use this section to discuss your feelings about what has happened to you as a result of the crime and how it has affected your general well-being. Please check all the reactions you have experienced.

¨	Loss of sleep	¨	Lack of concentration	¨	Fear of strangers	¨	Marital problems
¨	Nightmares	¨	Fear of being alone	¨	Anger	¨	Loss of security/control
¨	No trust in anyone	¨	Anxiety	¨	Cry more easily	¨	Thoughts of suicide
¨	Serious change in appetite	¨	Job stress	¨	Family not as close	¨	Feelings of helplessness
¨	Depression	¨	Want to be alone	¨	School stress	¨	Fear of leaving home
¨	Other

*PHYSICAL INJURY.* Use this section to discuss what physical injuries or symptoms were suffered as a result of this crime. You may want to write about the extent of the injuries, how long your injuries lasted, and if you received and/or where you received medical treatment for your injuries. If more space is required, please use additional pages.




Indicate medical treatment received. Attach a doctor’s statement if you wish.		¨ Treated at the scene only	¨ Treated at medical center
		¨ Hospitalized for ___ days	¨ Other (Please explain)

ECONOMIC LOSS. Use this section to record the extent of economic and financial loss as a result of this crime. You may want to begin a journal of economic loss as soon as possible after the crime occurred. In the event of a conviction, this information may be used later by the presiding judge to determine any restitution owed by the defendant.
Estimate of Economic Loss	Cost to Date			Future Expected Costs
Loss of income from work	$			$
Property loss or damage	$			$
Doctor/hospital bills	$			$
Counseling expenses	$			$
Emergency transportation	$			$
Crime scene cleanup	$			$
Moving expenses	$			$
Funeral expenses (If applicable)	$			$
Other (Please explain)	$			$
	$			$
Amount covered by insurance	$			$

Feel free to attach copies of receipts, bills, and canceled checks. Are copies attached?					o Yes	o No
Have you applied for Crime Victims’ Compensation through the Attorney General’s Office in Austin?					o Yes	o No
If you have not, you may apply at www.texasattorneygeneral.gov
If you have, please provide your claim number:

The information in this Victim Impact Statement is true and correct to the best of my knowledge.

____________________________________________

Print Name

____________________________________________ _________________________

Signature Date

Information submitted by: ¨ Victim ¨ Parent/Guardian ¨ Close Relative ¨ Other _____________________

VIS (Rev 9/2009)

VICTIM IMPACT STATEMENT

The information in this Victim Impact Statement is true and correct to the best of my knowledge.

____________________________________________

Print Name

____________________________________________ _________________________

Signature Date

Information submitted by: ¨ Victim ¨ Parent/Guardian ¨ Close Relative ¨ Other _____________________

VIS (Rev 9/2009)

FILL OUT THIS PAGE ONLY IF THE DEFENDANT HAS A COURT ORDER THAT GRANTS HIM OR HER POSSESSION OR ACCESS TO THE
MINOR CHILD. NOTIFICATION TO THE APPROPRIATE COURT WILL BE MADE PRIOR TO THE DEFENDANT’S/RESPONDENT’S RELEASE.

This information will be used by the Texas Department of Criminal Justice-Victim Services Division if the defendant/respondent in this case is
incarcerated on this offense involving this child victim.

SECTIONS 1 & 2. To be completed by the victim, parent/guardian or close relative of the victim.

Provide information regarding the existing child custody order involving the defendant, and NOT the current criminal offense or conviction.