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DOUGLAS COUNTY DISTRICT ATTORNEY’S OFFICE CRIME VICTIM IMPACT STATEMENT VICTIM’S NAME: ADDRESS: EMAIL ADDRESS: PHONE (Home) (Work) _ (Cell) NAME OF PERSON OTHER THAN VICTIM COMPLETING FORM: RELATIONSHIP TO VICTIM: DEFENDANT’S NAME: DATE CRIME OCCURRED: 1. In your own words, briefly describe the crime committed against you and/or your family (Additional pages can be attached to answer this or any of the following questions.) 2. If you were physically injured because of this crime, did your injuries require medical attention? If yes, please describe the injury. What medical facility treated your injuries and how long was or will the treatment be needed? 3. Were you or your family emotionally impacted because of this crime? If yes, how? (OVER) ---PAGE BREAK--- FINANCIAL LOSSES THAT YOU ARE SEEKING RESTITUTION FOR: TYPES OF LOSS AMOUNT PAID BY YOU AMOUNT PAID BY INSURANCE MEDICAL BILLS COUNSELING PROPERTY DAMAGE PROPERTY LOSS CHECK FRAUD FINANCIAL CARD FRAUD TOTAL: $ TOTAL: $ INSURANCE COMPANY INFORMATION (IF APPLICABLE) NAME: PHONE: POLICY 4. Have you been informed of the Georgia Crime Victim’s Compensation Program? If so, have you completed and submitted an application? Visit crimevictimscomp.ga.gov for more information. 5. Please share any additional views you would like to express. This Victim Impact Statement is signed and affirmed as true under the penalties of perjury. Signature: Date: MAIL/FAX/DROP OFF TO: DOUGLAS COUNTY DISTRICT ATTORNEY’S OFFICE VICTIM/WITNESS PROGRAM 8700 HOSPITAL DRIVE, 2ND FLOOR DOUGLASVILLE, GA 30134 FAX: (678) 838-2075 OR EMAIL DIRECTLY TO: