Form Center

2. OFFICE OF THE PROSECUTING ATTORNEY
4. VICTIM/WITNESS SERVICES DIVISION
6. 411 Jules, Room 132, St. Joseph, Missouri 64501
8. Crime Victim Impact Form
12. All victims of crime suffer in one way or an other. Please complete and submit this form so we can tell the judge at sentencing how the impact of this crime has affected your life.
16. Defendant Information:
18. Defendant's Name:
20. Date of Incident:
22. Charge:
26. Victim Information:
28. First Name
29. Last Name
31. Address1
33. Address2
35. City
36. State
37. Zip
39. Daytime Phone Number:
40. Evening Phone Number:
42. Additional Phone Number:
43. Email address:
45. Relationship to victim:

    1. Self
    2. Mother
    3. Father

    1. Grandparent
    2. Other Relative
    3. Friend
47. Name of closest relative or friend:
49. Address:
53. Crime Impact Information
55. Please state what impact this crime has had on your life or the lives of your family:
57. Were you injured? (describe):
59. Was your life or physical well-being threatened?
61. Do you have a suggestion as to the appropriate punishment for the defendant? (describe)
65. Restitution Claim:
67. Nature of your claim?

    (Check all that apply.)

    1. Medical Expenses
    2. Damaged Items

    1. Missing Items
    2. Other
69. Estimated TOTAL $ value of your loss:
71. Are any of these items covered by insurance?

    1. Yes

    1. No
73. $ Value of insured items:
    (Bring copies of bills, receipts, estimates, etc. to our office.)
75. Did your loss include anything with sentimental or irreplaceable value?
    (Describe)
79. Crime Victims' Rights
81. As a crime victim you have several rights resulting from the passage of the Missouri Constitutional Amendment for Crime Victims in 1992 (Chapter 595.209, RSMo.). Among the constitutionally guaranteed rights, is the right to be informed of court dates and sentencing decisions upon written request. If you would like to be informed of court dates related to the above-named defendant, please check the appropriate box.
83. Please select one:

    1. I would like to be NOTIFIED BUT DO NOT WISH TO APPEAR at hearings for bond, preliminary hearing, pre-trial, plea, sentencing/disposition, probation revocation and/or post conviction release.
    2. I would like to be NOTIFIED AND PRESENT at hearings for bond, preliminary hearing, pre-trial, plea, sentencing/disposition, trial, probation revocation and/or post conviction release.
    3. I do NOT wish to be notified or present. (Please be aware that your presence may be required at trial or hearing.
85. Today's Date:
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field