Victim Impact Statement

Victim's Name Defendant's Name
Victim's Email: Victim's Cell Phone:

This Victim Impact Statement has been developed to benefit victims of crime and to bring your thoughts and concerns to the attention of the Court and Prosecutor. Please fill out this form and attach any additional pages or letters if necessary.

In 2015, the Utah Legislature passed HB 348 (Justice Reinvestment Initiative), touted as the most significant criminal justice reform bill in decades. JRI is an all-encompassing effort to make the Courts and Board of Pardons and Parole selective about who they send to jail and prison, focusing on treatment and community based programs instead. Thus, the criminal justice system now, under JRI, is looking for options other than jail and prison.

This form will become a part of the court record and may be seen by the defendant(s) and his/her attorney.

1. What was the emotional impact of this crime on you and your family?

2. Were you physically injured?

3. Do you have any concerns about your safety? If yes, describe your concerns.

4. Would you like the Judge to issue a "no contact" order instructing the defendant to stay away from you and your family?

5. Have you or your family received or requested counseling or therapy because of this crime? Have you or your family applied for Crime Victim Reparations?

6. Please express your feelings about any plea negotiations that may take place.

7. If you know the defendant personally, do you think the defendant would benefit from any of the following (check all applicable boxes).

To send supporting documents, receipts, or estimates related to restitution or this case,
please send them by email to