First Name:

Middle Name:

Last Name:

Suffix: --None-- Jr. Sr. II III Victim Representative:(Only if victim is a minor, business, deceased or incapacitated) Relationship to victim: --None-- Brother Sister Father Mother Other Mailing Address: City / State / Zipcode: Email Address

Financial Information (If Applicable)

Expenses (Proof Of Loss Will Be Required)

Medical $: Counseling $: Funeral $: Property Loss / Damage $: Insurance Deductible Amount $: Other $:

Recovered Amounts (If Applicable)

Victim Compensation (SOVA) $: Insurance Reimbursement $: Insurance Company & Address:

Please read and complete the next five statement with a Yes or No

I DO wish for this case to be DISMISSED. I do not wish to proceed with prosecution. --None-- Yes No I DO agree for the accused to receive Pre-Trial Intervention instead of going to court if possible. --None-- Yes No I DO wish to be notified of all court proceedings pertaining to this case. --None-- Yes No I DO wish to be notified of all post-conviction hearings, including appeals, probation, parole, release, or escape from prison, etc. --None-- Yes No I DO NOT wish to be notified of any court proceedings or post conviction hearings as listed above. --None-- Yes No

This portion of the Victim Impact Statement requests information about the effects of the crime. Please consider the following questions and respond only to those that apply to you and to this case.

Did you suffer any physical injuries?: --None-- Yes No Did these injuries cause any permanent or long-term disabilities or disfigurements?: --None-- Yes No Have you noticed any change in your lifestyle since this crime happened?: --None-- Yes No Did this crime affect you financially?: --None-- Yes No Have you received any counseling as a result of this crime?: --None-- Yes No If not, are you interested in receiving counseling?: --None-- Yes No Please use the space below for additional comments or information you would like us to know about this crime:

Thank you for taking the time to complete and return this form. This will help your voice be heard by the criminal justice system. An informative confirmation email will be sent to the email address you provided above. Confirm the email address is correct before submitting and be sure to check your spam/junk folder for the email confirmation. Any additional comments or information you would like to provide can be emailed to info@solicitor4.com. Scanned copies or photo copies can be emailed to info@solicitor4.com for all proof of loss (statements, invoices, estimates, insurance policy information, medical bills, etc.). Please remember it is your responsibility to notify the Fourth Circuit Solicitor’s Office if you have a change of address or phone number.

Please remember it is your responsibility to notify the Fourth Circuit Solicitor's Office if you have a change of address or phone number.

Signature (Typed):