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Victim Impact Statement Packet English
Victim Impact Statement Packet English
ATENCIÓN: Si Ud. requiere asistencia en español o tiene preguntas sobre este documento,
favor de llamar al #______________________________.
VICTIM IMPACT STATEMENT PURPOSE AND IMPORTANCE
This Victim Impact Statement (VIS) will be used throughout the
criminal justice system (by the prosecutor, the judge, and the parole
board) to better understand the emotional/psychological, physical,
and financial impact of the crime.
The contact information you provide in this Victim Impact Statement
is important and will be used to contact you if you wish to receive case
information from:
Community Supervision and Corrections Department
(probation);
Texas Department of Criminal Justice (prison); and
Texas Board of Pardons and Paroles.
Return the
Confidential Victim Contact Information
page and the
Victim Impact Statement Form
to the county or district attorney’s office
that is prosecuting your case.
TO BE COMPLETED BY THE VICTIM ASSISTANCE COORDINATOR
Victim Assistance Coordinator:
Agency:
Address:
City: Zip Code:
Work Phone: Fax:
E‐mail:
Defendant(s) Name (Last, First MI) Case/Cause #
If any of your contact information changes, you must notify the following departments, as applicable, to make sure you are kept
informed:
Trial/Prosecution Phase Victim Assistance Coordinator (see previous page for contact information)
Defendant is sentenced to Adult Probation The county’s community supervision and corrections department.
http://tdcj.state.tx.us/documents/CSCD_directory.pdf
Defendant is convicted and sent to TDCJ (Adult TDCJ Victim Services Division 1‐800‐848‐4284 or
Prison) [email protected]
3. VICTIM IMPACT STATEMENT FORM: Victims have the right to submit a Victim Impact Statement. The Victim Impact Statement is
a written, detailed account of the emotional/psychological, physical, and financial impact of the crime on the victims and/or family
members. This document can be used to explain your feelings such as loss, frustration, fear, and/or anger, as well as any physical
or monetary damages due to the crime. Only you can provide this vital information.
KNOW HOW YOUR VICTIM IMPACT STATEMENT IS USED
Prosecutor:
Considers your Victim Impact Statement before entering into a plea bargain agreement.
Considers your Victim Impact Statement to determine the restitution amount to request (if applicable).
Judge:
Considers your Victim Impact Statement before imposing a sentence; the Victim Impact Statement is not considered by a
jury.
Considers your Victim Impact Statement before a plea bargain agreement is accepted.
Considers your Victim Impact Statement to determine the restitution amount (if applicable).
Defense:
May request to review your Victim Impact Statement, excluding the Confidential Victim Contact Information page
In certain circumstances, the defense attorney, with court approval, can introduce testimony or other information alleging a
factual inaccuracy in the statement.
Community Supervision (Probation):
Considers your Victim Impact Statement for notification purposes.
Texas Department of Criminal Justice:
If the defendant is sentenced to prison, your Victim Impact Statement goes to the TDCJ Victim Services Division to provide
adults requesting notification with information regarding the defendant. Adults can register for this service by completing
the Confidential Victim Contact Information page, which is a part of the attached Victim Impact Statement.
Victims can also utilize the form to indicate their preference for the TDCJ to prohibit the defendant from contacting them.
Texas Board of Pardons and Paroles:
A parole panel will consider your Victim Impact Statement prior to voting whether or not to release the offender to parole
supervision.
I M P O R T A N T !
BEFORE RETURNING THE VICTIM IMPACT STATEMENT, BE SURE TO CHECK YOUR PREFERENCES IN SECTION 1 AND REVIEW
AND SIGN THE FINAL DOCUMENT. IF YOU MOVE OR CHANGE ANY OF YOUR CONTACT INFORMATION, CONTACT YOUR
VICTIM ASSISTANCE COORDINATOR, THE COMMUNITY SUPERVISON AND CORRECTIONS DEPARTMENT (PROBATION), OR
THE TEXAS DEPARTMENT OF CRIMINAL JUSTICE VICTIM SERVICES DIVISION.
SECTION 2. CONFIDENTIAL VICTIM CONTACT INFORMATION (Please use black ink and print clearly)
Victim’s Name: DL No. and State:
Date of Birth: Male Female
Name of Person
DL No. and State:
Submitting this Statement:
Address: Date of Birth:
City: State: Zip:
Home/Cell Phone: Work Phone: Alternate Phone:
Email Address: Relationship to Victim:
Please provide the contact information of someone who will know how to contact you.
Full Name:
Address:
City: State: Zip:
Cell Phone: Work Phone:
Email Address: Relationship to Victim:
Revised 10/12/2017
RETURN TO YOUR
VICTIM ASSISTANCE COORDINATOR
VICTIM IMPACT STATEMENT
TO BE COMPLETED BY THE VICTIM ASSISTANCE COORDINATOR
Victim Pseudonym (If Applicable):
Offense: Offense Date:
Defendant(s) Name (Last, First MI) DPS State ID (SID) DOB Case/Cause # Court #
Please do not relate any information about the crime itself, those facts are available in other reports.
The Victim Impact Statement is a written, detailed account of the emotional/psychological, physical, and
financial impact of the crime on the victims and/or family members. It may be used at each phase of the
criminal justice process, including the prosecution of the offense, sentencing to community supervision,
incarceration in the Texas Department of Criminal Justice Correctional Institutions Division, and through the
parole review process. Please answer only as many questions as you wish. If you need more space, attach
additional page(s) to the Victim Impact Statement.
TO BE COMPLETED BY THE VICTIM, PARENT/GUARDIAN OR CLOSE RELATIVE OF THE VICTIM
Victim’s Name:
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.
Changes in sleep pattern Lack of concentration Fear of strangers Loss of security/control
Marital/Relationship problems
Has the victim or the victim’s family sought counseling as a result of the crime? Yes No
How has the crime affected you, your family or those close to you? Please feel free to discuss your feelings,
thoughts, and general well‐being. (Please attach any additional page(s) if needed.)
Revised 10/12/2017
RETURN TO YOUR Page 2 of 3
VICTIM ASSISTANCE COORDINATOR
VICTIM IMPACT STATEMENT
PHYSICAL INJURY. Use this section to discuss any physical injuries suffered as a result of the crime. You may
want to write about the extent of the injuries and how long the injuries lasted. (Please attach additional
page(s) if needed.)
Treated at ________________________________________ ( medical centers / clinics / physicians’ offices)
Hospitalized at _______________________________________________________________ for ____ days
FINANCIAL LOSS.
Losses you have incurred as a result of the crime may include medical and dental care, emergency
transportation, property loss or damages, loss of income from work, counseling, crime scene cleanup, moving
or changing residence, funeral costs, and other costs of this nature.
You may want to begin keeping a log of your financial loss as soon as possible after the crime occurred to
include any receipts and records you have. In the event of a conviction, the prosecutor or judge may use this
information to determine if any restitution, funds paid by the offender and owed to the victim, may be
ordered or you may be contacted for more up‐to‐date information. PLEASE KEEP COPIES FOR YOUR OWN
RECORDS.
Please provide a best estimate of your financial loss to date: $
Do you anticipate any future costs resulting from the crime? Yes No
Were any expenses covered by insurance or other sources? Yes No
Have you applied for Crime Victims’ Compensation through the Attorney General’s Office? Yes No
If you have not, you may apply at www.texasattorneygeneral.gov or call 1‐800‐983‐9933.
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 Other ______________________