10 EAST PARK SQUARE SUITE 500 MARIETTA, GA 30090-9638
770-528-8500
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.
Victim's Name
Mailing Address
Person other than the victim, completing the statement must provide the following information.
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?
If yes, use the fields below to list them. For court use please attach copies of bill and receipts.
Date
Signature
