VICTIM IMPACT STATEMENT

STATE OF SOUTH CAROLINA	)
)	IN THE SUMMARY COURT
COUNTY OF	)
)	CASE NUMBER
)
)
Vs.	)
)
)

Name of Victim:

1.	Home Address
2.	Home Phone
Work Phone
Other #
3.	List economic loss and, if applicable, recovery of economic loss from other sources which resulted from the crime (i.e. insurance policy, etc.) (attach additional sheets if necessary).
a.
b.
c.
d.
4.	Describe any physical or psychological injuries, or both, including their seriousness and permanency which resulted from the crime. (attach additional sheets if necessary).
5.	List any psychological services requested or obtained which resulted from the crime. (attach additional sheets if necessary).
6.	Describe any changes in your personal welfare or family relationships which resulted from the crime. (attach additional sheets if necessary).
7.	List other important and pertinent information. (attach additional sheets if necessary).
8.	Please check one of the following.
I would like to be notified of any court proceeding on this case
I do not wish to be notified of any court proceeding on this case

Signature of Victim
Date

SCCA/561 (11/97)

mbaughman

2010-03-02

wclark

SC Judicial Department