Victim Impact Statement District & Juvenile

VICTIM IMPACT STATEMENT

RETURN IMMEDIATELY (unless you have already done so previously)

Date Mailed:

Mail to: Victim Witness Unit

(Address, Prosecuting DA)

Phone Prosecuting Office; FAX DA Office

Next Event: (Name of Hearing) Date: (Hearing Date)

Notification Person: YOUR NAME/YOUR BUSINESS

Case: Defendant Name(s)

Court Case Number

Division: Prosecutor ID#/Ct Room

Colorado allows victims of crime to submit a statement, which describes the impact of the crime(s) on the victim and/or his/her family. This statement may be considered by the Court in deciding the sentence. Please complete all parts of this form that are important to you; add pages if necessary. Return the form even if you are not claiming any losses.

Do you wish to complete this form? YES____ (complete the sections important to you)

NO_____ (you are not claiming any losses)

Do you plan to be at the sentencing? YES____ NO____

(Click Here for specifics on the above; click on the line for more information on each section)

1. EFFECTS OF THIS CRIME ON YOU/YOUR FAMILY: Please describe injuries, costs, damages and overall effect of this crime on you, your family, and/or your business. Include fears, lifestyle changes, etc. Attach additional pages as needed.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. SENTENCING CONSIDERATIONS: Add your thoughts about what you would like the Magistrate/Judge to consider at sentencing and the punishment you feel is fair. Attach additional pages as needed.

3. INSURANCE INFORMATION: (Mark the boxes that apply to you and fill out the information):

A. Your insurance company paid for expenses:

1. Medical Insurance: Company Name______________________________________

Claim No.__________________________ Phone Number:___________________

Medicaid ID No._________________________________________

Medicare (Part A/B) ID No.________________________________

2. Car/Home Owner’s Insurance: Company Name______________________________

Claim No.__________________________ Phone Number:___________________

B. You do not have insurance or didn’t file a claim.

C. You have applied to Victim Compensation, the claim is in process, but no payments have been made; OR

Victim Compensation has paid some or all of your bills (Link to VC website address)

D. Defendant or his/her insurance paid your costs.

4. RECOVERED PROPERTY: If police recovered your property, list item and mark whether it was returned to you. If the recovered item was damaged – please note that in this section. Attach additional pages, if needed

Item	Returned?		After sentencing, call the District Attorney’s Office to get your property released.
Item	Yes	No

5. LOSSES: In this section, list the costs you had because of this crime. Attach copies of bills, receipts, estimates, payroll check stubs, and/or a full explanation to prove your loss. Feel free to call if you have questions.

Description of Loss	Amount You Paid

6. CLAIM FOR RESTITUTION: Please print your total costs in the box below, taking into consideration items recovered (if any). Send back the completed form.

YOU ARE ASKING FOR RESTITUTION IN THE AMOUNT OF: $__________________

YOU ARE NOT ASKING FOR RESTITUTION

IMPORTANT INFORMATION:

1. A copy of this statement will be sent to the Court, defendant/or defense counsel, and the district attorney.

2. The Magistrate/Judge will not order restitution for pain and suffering.

3. Although every effort will be made to collect restitution ordered by the Court, there is no guarantee of payment. It may be advisable to discuss your options for a civil recovery with a private attorney

4. The defendant has the right to challenge your restitution amount and can request a restitution hearing. If there is a hearing, you will be asked to testify.

5. Let us know immediately whenever your address changes, even after the case is closed. If restitution is ordered, it is normally paid in small monthly payments over a long period of time. Sometimes, restitution is paid years after sentencing and the Court Registry will need a current address.

6. Keep a copy of this form and attachments!

CERTIFICATION AND RELEASE:

I do hereby swear that the above information is true and correct to the best of my knowledge and belief. Further, I authorize release of information by the above-named insurance companies/medical providers to the 18^th Judicial District Attorney’s Office for purposes of establishing restitution.

Signature Date __________________

Printed Name Title ____________________________________

Phone Number(s) Where I Can Be Reached:

Daytime__________________________ Evening___________________ Cell___________________________

Victim Impact Statement District & Juvenile

Item

Returned?

Yes

No

Description of Loss

Amount You Paid

5. Let us know immediately whenever your address changes, even after the case is closed. If restitution is ordered, it is normally paid in small monthly payments over a long period of time. Sometimes, restitution is paid years after sentencing and the Court Registry will need a current address.

18th Judicial District

News & Upcoming Events

Reporting a Crime

E-Mail the D.A.