Office of the Solicitor - Fourth Judicial Circuit

William B. Rogers, Jr.

Victim Impact Statement

To be completed by victim or victim representative

Please submit this form within 10 days. Failure to do so may result in your receiving no further hearing notifications or information regarding your case. Assistance in completing this form is available upon request.

Victim Information

(Only if victim is a minor, business, deceased or incapacitated)

Financial Information (If Applicable)

Expenses (Proof Of Loss Will Be Required)

A scanned copy or photocopy of statements, invoices, estimates, insurance policy information, medical bills, etc. can be emailed to for all proof of loss.

Recovered Amounts (If Applicable)

Please read and answer YES or NO to the following questions:

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.

Confirm the following statements by selecting each box:

Thank you for taking the time to complete and submit your victim impact statement. This will help your voice be heard by the criminal justice system.