|
||||
 |
||||
 |
|
This document is also available as in Adobe Acrobat Porable Document Format (PDF). |
Witness Assistance ServiceYou can fill in this form or write your statement in your own way. YOU DO NOT HAVE TO USE THIS FORM. YOU DO NOT HAVE TO COMPLETE EVERY SECTION.
1.PhysicalThis may include the injuries you received, any treatment you may have had and the ongoing physical effects. If you have additional information, such as a doctor’s report, you can attach it to this form.
2.EmotionalThis may include psychological or emotional effects on your sense of wellbeing and enjoyment of life. If you have additional information, such as a report from a psychologist or counsellor, you may attach it to this form.
3.FinancialThis may include loss of wages or income or other expenses incurred as a result of the crime. If you have additional information, such as your pay slip, you can attach it to this form.
4.Property damage or lossThis may include damage to clothing, glasses, tools, your home, or loss of property which has not been recovered. If you have additional information you can attach it to this form.
5.Other relevant informationThis may include information such as how your life has changed as a result of the crime, and anything else you want to tell the judge or magistrate which has not been included in other sections. If you have additional information you can attach it to this form.
6.SentenceYou can include what you would like the judge or magistrate to order in relation to the offender such as imprisonment, fine or bond.
I consent to the presentation of this Victim Impact Statement to the judge or magistrate. Name: Signature: Date:
|
