COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. WHITFIELD COUNTY JUVENILE COURT : JUDICIAL SUBPOENA VICTIM IMPACT STATEMENT Plaintiff(s) -against- : SEND THE COMPLETED FORM TO: Whitfield County Juvenile Court County Courthouse Annex 301 W. Crawford Street Dalton, Ga. 30720 : : Case No: Court Officer: Offense: Defendant(s) Offense Date: : ...................................................... THE TO Georgia law provides that in appropriate cases, children, who by their behavior have caused others to suffer economic loss, can be ordered to compensate their victims. It is the policy of this Court, in appropriate cases, PEOPLE OF restitution OF NEW YORK the treatment and rehabilitation of the to order THE STATE consistent with child. The information you provide may help the District Attorney, Judge and Court Staff better understand how the child’s behavior has affected you and your family. Attach more sheets if necessary. If this statement is considered by the Judge before a dispositional hearing, it will also be given to the child’s attorney. Victim’s Name ___________________________________ other than Victim completing this Statement _____________________________ Relation of Victim (family member or attorney) ___________________________ StreetCOMMAND YOU, that all business and excuses being laid aside, you and each of you WE Address _________________________________________________________________ City, State, Zip Code __________________________________________________________ Honorable Phone Numbers __________________________________________________________ at the Court Contact GREETINGS: Person attend before , the located at County of 1. Briefly tell about the offense that was committed against you (or your family member). in room , on the day of , 20 , at o'clock in the noon, and at _____________________________________________________________________________________________________ any recessed _____________________________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 2. Were you physically injured because of this offense? _________ If yes, tell the kind of injury and the amount of injury. Tell how serious it was. Tell how long the injury last or will last. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 3. Was medical treatment needed for your physical injury? ______ I yes, tell about the treatment. Tell how long the treatment was or will be needed? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _________________ Witness, Honorable Court in County, , one of the Justices of the day of , 20 4. Were you or your family psychologically (emotionally) injured because of this offense? ______ If yes, tell how this injury has affected your or your family. (Psychological injury may include change in attitude or feelings, fear, change in lifestyle, emotional problems, et.) _____________________________________________________________________________________________________ (Attorney must sign above and type name below) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. Have you or your family received counseling or therapy because of this offense? ______ If yes, tell how long you or your family member have received counseling or therapy. __________________________________________________________________________________________________ Attorney(s) for 1 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. 6. Has this offense affected your ability to earn a living? ______ If yes, tell how. Mention any days lost from work. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ : Plaintiff(s) -against- JUDICIAL SUBPOENA : 7. Has this offense in any way affected your family relationships? _____ If yes, explain. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ : : 8. Have you had any expense or economic loss because of this offense? ______ If yes, use the columns below to list them. See page 2 for additional information. Defendant(s) : E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XP.ENSE.S. . . . . . . . . . . KIND OF EXPENSE Medical/Hospital Treatment, Counseling, Other Amount of Expense at this Time $ _____________________ _____________________ _____________________ _____________________ ____________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ THE PEOPLE OF THE STATE OF NEW YORK TO KIND OF LOSS Property Stolen, Damaged or Destroyed (Place “R” after Recovered stolen item and do not list value in next column _____________________________________________ _____________________________________________ _____________________________________________ GREETINGS: Value of Loss at this time $ __________________ __________________ __________________ Lost Wages/Income $ _________________ Number of lost Work Days _____________________________________________ WE COMMANDLoss that all business and excuses being laid aside, you and each of you attend before YOU, Any Other Kind of _____________________________________________ the $ __________________ , the Honorable at Court located at CountyEXAPECTED FUTURE KIND OF EXPENSE of Estimated Future Amount of Expense in room ____________________________________________, 20 , on the day of , at o'clock in the noon, and at any recessed $ _________________ ____________________________________________witness in this action on the part of the _________________ or adjourned date, to testify and give evidence as a TOTAL OF PRESENT AND ESTIMATED FUTURE EXPENSES AND Losses. $ _________________ 9. Tell about any other change in your personal welfare or other problem you or your family have experienced because of this offense. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. This statement is signed and affirmed as true under penalties of perjury. Signature _________________________________________ Date _________________________________ Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for 2 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. WHITFIELD COUNTY JUVENILE COURT : DALTON, GEORGIA JUDICIAL SUBPOENA Plaintiff(s) -against- : NOTICE TO PERSONS WHO SEEK RESTITUTION FROM JUVENILES BEFORE THE WHITFIELD COUNTY JUVENILE COURT : Re: Economic Loss : You may have been asked to provide this information by a law enforcement officer, member of the District Attorney or Juvenile Defendant(s) : . . . . . . Court . staff. . . . . . asked. . to. .testify. . in . .Court, please be prepared to . . . . . . . . . . . . . If . . . . . . . . . . . . . . . . . . . . . prove the economic loss. Proof of economic loss may be established by: (1) THE PEOPLEValue of the OF NEW YORK OF THE STATE property before being damaged, and the value of the property after damage. TO (2) Expenses for the repair of the property or estimates for the repair of the property. If injured, bring a doctor’s statement describing the injuries GREETINGS: and bring your medical bills. Listed below is a list to help remember what to bring to Court. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County1 Medical bills of 1 (deductible), 20 in room Insurancethe , on policyday of , at o'clock in the noon, and at any recessed 1 lost wages (number evidence as a witness injob)action on the part of the of hours lost on this or adjourned date, to testify and give 1 Invoices 1 Proof of purchase 1 photographs Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to If unable this subpoena was issued for a maximum penalty of $50 and all loss. the party on whose behalfto bring the above, be able to give testimony about your damages sustained as a By being prepared to result of your failure to comply.testify as to your economic loss, you may prevent having to Court appear at a second hearing. You may want to talk to an attorney. Also your time may be recoverable. You may need an Witness, Honorable expert witness to testify as to your loss. of the Justices of the , one You may contact the Brenda Hoffmeyer at the Victim’s Assistance Office at 272in County, day , 20 2273 if you have questions. of (Attorney must sign above and type name below) Attorney(s) for 3 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com