Victim Impact Form

PURSUANT TO NH LAW, RSA Section 21-M:8-k - Rights of Crime Victims

Victim Impact Statements may be considered by the court in deciding a sentence. Please complete all parts of this form which apply and add additional pages, as necessary.

Defendant Name *

Date of Arrest/Incident *

Month

Day

Year

PIN *

Victim’s Name *

DESIRED OUTCOMES *

Although it is the responsibility of the court to impose the final sentence, your opinions are important. What would you like to see happen with this case? (jail/probation/fines/treatment – chemical, anger, domestic, or mental health/ restitution/etc.)

Would you like the Judge to issue a “No Contact” Order instructing the defendant to stay away from you, the victim, and/or your family? *

Yes

Signature of Person Completing form: (type name) *

Date of Form Completion: *

Month

Day

Year

Leave this field blank

Victim Impact Form

PURSUANT TO NH LAW, RSA Section 21-M:8-k - Rights of Crime Victims

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