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Glendale, AZ
Glendale City Prosecutor's Office
6815 N 57th Ave
Glendale, AZ. 85301
(623) 930-3475



Victim Impact Statement Form
This statement is used to assist the Prosecutor and Court in their effort to weigh all factors and to impose a fair sentence. Your cooperation is appreciated.

From(your name):*
Docket Number:
Proceeding Date:
Home Phone Number:
Cell Phone Number:

Was the defendant known to you before this incident occurred?
If "Yes", please indicate your relationship:
If there is a history of this type of behavior, please list the incidents, the city where it occured, and the approximate dates.
What, if any, physical injury or disability have you suffered as a result of this incident?
Explain any medical treatment received, as well as any recurring implications.
What was the emotional impact of this incident on you? How did it affect your life?
Was the emotional impact such that you now, or have
in the past, been involved in counseling? When/How?
What do you feel would be a fair sentence in this case? Fine
Jail -- How long?
Probation -- How long?

If probation were given to the defendant, what special terms would you suggest? Not to threaten, harm, or harass the victim.
Attend a drug/alcohol counseling program.
Attend an anger management program.
Pay Restitution.
Not to go near the victim's home.
Not to go near the victim's school.
Not to go near the victim's work.
Other suggestion:
I hereby certify that the above information is true and accurate and that I am the above signed person.
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