Section 1 of 4 in this document

ATTORNEY WORK PRODUCT

GEORGIA VICTIM IMPACT STATEMENT

Defendant

Case Number

Crime

Date Crime Occurred

Information you give below may help the Prosecutor, Judge, and Probation Office better understand how this crime has affected you and your family. You may want to attach more if necessary.

Phone

Person other than the victim, completing the statement must provide the following information.

Relationship to Victim

Reason victim did not complete the statement

Section 3 of 4 in this document

Date

Signature

First Name

Last Name

Choose how to sign

Draw Type

This statement is signed and affirmed as true under the penalties of perjury.

ATTORNEY WORK PRODUCT

GEORGIA VICTIM IMPACT STATEMENT

Date Crime Occurred

2. Were you physically injured because of this crime?

3. Was medical treatment needed for your physical injury?

4. Were you or your family psychologically (emotionally) injured because of this crime?

5. Have you or your family received counseling or therapy because of this crime?

6. Has this crime affected your ability to earn a living?

7. Has this crime in any way affected your family relationship?

8. Have you had any expense or economic loss because of this crime?

Date

Signature

****ATTORNEY WORK PRODUCT****

GEORGIA VICTIM IMPACT STATEMENT

Date Crime Occurred

Victim's Name

Mailing Address

Name

2. Were you physically injured because of this crime?

3. Was medical treatment needed for your physical injury?

4. Were you or your family psychologically (emotionally) injured because of this crime?

5. Have you or your family received counseling or therapy because of this crime?

6. Has this crime affected your ability to earn a living?

7. Has this crime in any way affected your family relationship?

8. Have you had any expense or economic loss because of this crime?

Date

Signature

ATTORNEY WORK PRODUCT