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VICTIM IMPACT STATEMENT DATE OF INCIDENT: VICTIM NAME: IN THE INTEREST OF: JUVENILE CASE AS A RESULT OF THIS CRIME, I EXPERIENCED THE FOLLOWING: (Please check all that apply and attach copies of bills or receipts.) PHYSICAL INJURY ___Emergency Room Treatment ___Time Off Work ___Physical Therapy ___Ambulance Services ___Doctor’s Exam & Treatment ___Permanent Damage/Scars EMOTIONAL INJURY ___Fear of Attacker/Re-Attack ___Difficulty in Sleeping ___Feelings of Violation ___Feelings of Anger ___Feelings of Helplessness ___Feelings of Shame ___Difficulty in Social Settings ___Difficulty at Work ___Difficulty in Personal Life ___Counseling/Therapy PROPERTY LOSS OR DAMAGE ___Clothing ___Personal Property ___Vehicle ___Home or Apartment FINANCIAL LOSS (Please attach copies of bills or receipts. Items without receipts may not be considered by the court). Total Loss Claimed Total Paid by Insurance Total paid by you Medical Expenses . . . Amount . . . . . . . . . . . . Insurance Paid Funeral Expenses . . . . Amount . . . . . . . . . . . . Insurance Paid $ Property Repair/Replacement $ Amount . . . . . . . . . . . . . Insurance Paid $ Counseling/Therapy Bills $ Amount . . . . . . . . . . . . . Insurance Paid $ Money Stolen . . . . . . . Amount . . . . . . . . . . . . . Insurance Paid $ Checks Forged/Stolen . $ Amount . . . . . . . . . . . . . Insurance Paid $ Lost Wages . . . . . . . . . $ Amount . . . . . . . . . . . . . Insurance Paid $ Insurance Company Name Insurance Agent and Telephone # ---PAGE BREAK--- EFFECTS OF THE CRIME: Briefly describe the effect this crime has had upon you. Theses effects may be physical, or financial. The information in this state- ment shall be considered by the court when deciding on a sentence in this case if the juve-nile is adjudicated. Please remember that this Impact Statement will be shared with the defendant in this case so YOU SHOULD NOT WRITE DOWN ANYTHING YOU DO NOT WANT THE JUVENILE TO READ. You may attach other papers if necessary. ---PAGE BREAK--- VICTIM RIGHTS INFORMATION As a victim of an act which resulted in a personal injury or damage to or loss of property which was allegedly committed by a child, you are entitled to the following information: 1. The procedure for obtaining the following. • Identity of the juvenile and the juvenile’s parents. • Juvenile’s police records. The specific procedure is found in s. 938.396(1r) Wis. Stats.: • Under ss. 938.396(1r), law enforcement agencies subject to their official agency policy may disclose information to the victim including the name and address of the juvenile and the juvenile’s parents. The names and addresses of the juvenile and the juvenile’s parents may also be disclosed by the victim witness coordinator under ss. 938.396(6). Any person who is denied access to this information may petition the court under ss. 938.396(5). 2. The potential liability of the juvenile’s parents for damages under s. 895.035, Wis. Stats. • A parent is liable for damages to property, for the value of unrecovered stolen property, or for personal injury attributable to a willful, malicious, or wanton act of the juvenile. • Recovery of damages from any parent or parents may not exceed the current limit allowed in small claims court for any one act of a juvenile in addition to taxable costs and disbursements and reasonable attorney files, as determined by the court. 3. Additional rights of victims. • The right to make a complaint to the Department of Justice concerning the treatment of crime victims under ss. 950.08(3) and to request a review by the Crime Victims Rights Board under ss. 950.09(2). - Contact Crime Victims Services (1-[PHONE REDACTED]). • The right to confer with an intake worker regarding any deferred prosecution agreement. • Information regarding any decision to close a case under ss. 938.24(5m) and information regarding any deferred prosecution agreement under ss. 938.245 • The right to be accompanied by a service representative under ss. 895.73. • The right to restitution under ch.938. • The right to compensation, as provided under ch. 949. • The right to a speedy disposition of the case under ss. 950.04(1v)(k). • The right to have personal property returned, as provided under ss. 950.04(1v)(s). This summary is prepared in accordance with ss. 938.346.