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VICTIM REQUEST FORM Your Name: In The Interest Of: Case Incident Date: Wisconsin law provides crime victims a number of rights. You may choose to exercise some, all, or none of these rights. Please check the rights you wish to exercise and return this completed form to the address below. If you do not return the enclosed forms within the next ten business days we will assume that you do not wish to exercise your rights in this matter and a resolution to this case will be reached without your input. To information about the procedure to obtain the identity of the juvenile and the juvenile’s parents, the potential liability of the juvenile’s parents, and the police reports regarding this incident. (Written instructions enclosed.) To confer (speak) with the Youth Services Intake Worker about possible outcomes of the intake evaluation including potential Informal Supervision recommendations. To confer (speak) with the prosecutor about possible outcomes of the prosecution including potential plea agreements and Sentencing, Consent Decree, or Dispositional recommendations. To request restitution for medical expense, damaged or lost property lost wages or other losses resulting from the crime committed against you (Restitution Request Form enclosed). To make a statement in person to the Judge at the time of the Sentencing, Consent Decree, or Dispositional Agreement (written Victim Impact Statement Form enclosed). To receive notice of the date, time, and place of all court hearings in this case. (Note; you will receive notice of any hearing where your testimony is required regardless of whether you choose to exercise this right.) To receive notice of the date, time and place of the sentencing, Consent Decree or Dispositional Agreement ONLY. To receive written information about the final disposition of the case. Signed: Please print your name: Address: Telephone: Please return this request form to: Douglas County Human Services 1316 N. 14th Street, Suite 400 Superior, WI 54880