VICTIM IMPACT STATEMENT

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 which apply to you; add pages if necessary. Please be accurate and complete; attach supporting documentation or verification.

Date Mailed:

If you HAVE NOT filled out this form before, PLEASE DO SO AND RETURN TO:

Victim /Witness Program-Barb Topliss

11th Judicial District, Office of the D.A.

136 Justice Center Rd., Room 203

Canon City, CO 81212

Phone: 719-269-0170

Next Event:


VICTIM NAME:

Notification Person: Barb Topliss

Defendant:

Case No.:

Division:

ATTORNEY:

I DO NOT wish to complete this Victim Impact Statement (   )

I PLAN TO BE PRESENT AT SENTENCING YES ______ NO ____

PART I. EFFECTS OF THIS CRIME ON YOU/YOUR FAMILY: Please describe injuries, losses, and overall effects of this crime on you, your family, and/or your business. Include things like fears and lifestyle changes. Attach additional pages as needed.

 
 
 
 
 
 
 

PART II. SENTENCING CONSIDERATIONS: Add your thoughts about what you would like the judge to consider at sentencing. Attach additional pages as needed.
 
 
 
 
 
 

(Fill out the Next Sections so we can ask for Restitution)

PART III. MEDICAL/DENTAL/THERAPY COSTS: List the bills you had because of this crime. Include doctor, clinic, hospital, and/or ambulance that treated you and prescription fees. Show what insurance paid. List YOUR ACTUAL LOSS in the last column. Attach copies of receipts, and additional pages as needed.

List Name of Doctor(s)/Hospital/Ambulance
Treatment Given
 Amounts Billed
Amounts pd by insurance
Your loss/
co-pay
       
       
       
TOTALS $ $ $

PART IV. PERSONAL/BUSINESS PROPERTY LOSS/DAMAGES:Describe what was stolen, lost or damaged (cash, goods, car, credit cards, checks). Estimate what the property WAS WORTH WHEN IT WAS LOST (based on condition, age). Subtract out what was covered by insurance. Show YOUR ACTUAL LOSS in the last column. We need copies of your receipts, if you have them. Attach additional pages as needed.

Describe -- What Was Stolen? Damaged?
Property Value @ Time of Crime
(-) Amt Pd by Insurance
Your Loss/ Deductible
       
       
       
TOTALS $ $ $

PART IV(A). RECOVERED PROPERTY: If your property was recovered by police, list item and indicate whether it was returned to you. Attach additional pages, if needed.

ITEM Returned:

Yes (   ) No (   ) After sentencing

Yes (   ) No (   ) Call the District Attorney's Office to get your property released

PART V. INSURANCE: By law, we can ask that defendant to repay your insurance company too, but we need your help. Please answer the following questions:

MEDICAL INSURANCE: Medical Insurance Co. Name

Agent/Adjuster Name Phone #:

Claim Number

CAR/HOME OWNER's INSURANCE: Insurance Co Name

Agent/Adjuster Name Phone #:

Claim Number

VICTIM COMPENSATION: Have you applied to Victim Compensation? If so, how much did it pay? $_________________

PART VI.: CLAIM FOR RESTITUTION:

YOUR CLAIM FOR RESTITUTION (Include receipts, estimates)
Medical Expenses (You Paid) $______________
Property Loss/Damages (You Paid) $______________
YOUR TOTAL LOSS ("Restitution") $______________
Without your statement, we cannot ask the judge for restitution. The law says that the court shall order defendant to make FULL RESTITUTION to the victim (and/or victim's immediate family) for actual damages. The judge may not order all the losses/damages you list. Keep in mind the defendant has a right to question each loss at a court hearing ("restitution hearing"). You may have to testify if defendant is granted a hearing.

CERTIFICATION & RELEASE: I do hereby swear that the following 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 11th Judicial District Attorney's Office for purposes of establishing restitution figures.

Signature: _____________________________________________

Printed Name: _________________________________________   Dated:__________

A copy of this Statement will be provided to the Court, defendant/or defense counsel and District Attorney. If your address changes let us know right away, even if the case is closed. If restitution is paid months/years from now, we'll need a current, correct address!