Victim Impact Statement Form

July 14, 2011

A victim impact statement form is used in the proceedings in a court for criminal justice process and to gather information about the physical, financial and emotional torture that a victim had to go through. The form shows the process in which the statement given by the victim and it is used to pass judgment in the court of law.

Sample Victim Impact Statement Form:



Report number of the police incident: ________________

Police reference number: ________________

Name of the defendant: ____________

Name of the convicted person: _________________

Details of the victim:


Name of the victim: _______________

Gender: _______________

Date of birth: __________

Address: ____________________________

Contact number: __________

How would you like to tell the court that how the offence has affected you?

a)   By reading out your statement to the court

b)   Give your statement verbally

c)   An official appointed by the court will read it out

Do you wish any compensation from the offender?


Details of impact on the victim by the offender:



Download Victim Impact Statement Form in Word Format

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