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 MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 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 No Signature of Person Completing form: (type name) * Date of Form Completion: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Leave this field blank Submit