Form 112 Victim Impact Statement and Request Form Re: docket #: Your Name: Date of Offense: 1. If the judge determines that the child has committed the delinquent act in question, the court may release the identity of the child to you if the court finds that release of the child222s identity is in the best interests of both you and the child. ( ) I REQUEST that the court tell me the identity of the juvenile for the following reasons: 2. The victim of a delinquent act has the right to file with the court a written or recorded statement of the impact of the act on the victim and the need for restitution. ( ) I enclose this form as my written statement of the impact of the delinquent act on me. ( ) I will send the court a separate written or recorded statement of the impact of the delinquent act on me and the need for restitution. ( ) I REQUEST to be present at the disposition (223sentencing224) hearing to tell the court how the offense has affected me. The reasons for this request are as follows: 3. The court will take a victim222s views into consideration in deciding the outcome (223disposition224) of the case. If you wish, you may use this form to describe the impact that this incident has had on you as the victim, including any physical injuries, emotional impact, and physical damage. a. Physical injuries requiring medical treatment? YES NO If yes, please describe your injuries and treatment: Do you have insurance that will cover costs of medical treatment? YES NO Name of insurance company Will there be any uninsured expenses related to medical treatment? YES NO UNSURE b. The emotional or psychological impact is: I will / will not be seeking counseling as a result of this incident. I do / do not have insurance that will cover the costs of counseling. American LegalNet, Inc. www.FormsWorkFlow.com c. Property damage is as follows: Total cost to repair/replace property: (Please attach bills, estimates) Total amount covered by insurance: Name of insurance company: What is your deductible? (Please attach copy of insurance policy showing deductible) d. I wish to request restitution For: Medical Expenses $ (Restitution can only be Counseling Expenses $ requested for UNINSURED Property Damage or Loss $ expenses) Vehicle Damage or Loss $ Other crime related expenses $ TOTAL EXPENSES: $ Amounts covered by insurance $ TOTAL RESTITUTION REQUESTED: $ e. I have recommendations for the outcome of the case. Here is my opinion and reasons: Signature Date Signature, if prepared by someone other than victim Date The purpose of this voluntary statement is to let the Court know how you feel about the delinquent act and how it has affected you emotionally, physically and/or financially. The court will provide a copy of this form to the defense attorney if you choose to complete it. If you have any questions, please call at (802) at the Court. Please return this form to the Court within two weeks of the date you receive this letter. 7/10 SML American LegalNet, Inc. www.FormsWorkFlow.com