Monmouth County Prosecutor’s Office

Victim Information Form

 

Prosecutor’s File # (found on cover letter) ________________________________________________

Your Name: ________________________________ Defendant’s Name: _______________________

If you are not the victim, how are you related to the victim? __________________________________

This Victim Information Form is a way for you to aid in the prosecution of the offender.  Please answer the questions that apply to your situation.

(1) If you were hurt during the incident, please describe your injuries:

____________________________________________________________________________

____________________________________________________________________________

(2) Did you require medical treatment because of the incident?                                      YES    or     NO

If so, where were you treated? __________________________________________

Dates of treatment ___________________________________________________

(3) Do you have medical insurance that will help you with the cost?                                    YES    or     NO

If yes, how much will or did you have to pay of your own money?                           $____________

(4) Do you need help filing a claim with the Victims of Crime Compensation Office?        YES    or     NO

You may be eligible to receive assistance with the costs of medical services, counseling, funeral

expenses or lost wages.

(5) Would you want the judge to consider ordering restitution?                                          YES    or     NO

If yes, how much?                                                                                                 $_____________

If the offender is found guilty, restitution is money that the offender may be ordered by a judge to pay back to you because of the crime. For the judge to consider ordering restitution, you must attach copies of bills, receipts or estimates of health care costs, stolen or damaged property. If you do not know these expenses yet, please send in the form now and forward bills as soon as you receive them.  There is no guarantee that the amount of restitution requested is the amount that the judge will order.

(6)  Do you need interpreting services or other special assistance to help you give a statement or testify?

If yes, what language and/or dialect? _______________________________              YES    or     NO

(7)  Did you have property damaged or stolen in this incident?                                            YES   or     NO

If so, please use the other side to list all items damaged or stolen and the cost of the item:

(8) Do you have property insurance that will help with the cost?                                       YES    or     NO

If yes, how much will or did you have to pay of your own money?                        $_____________

IMPORTANT:  Court rules require the prosecutor’s office to give a copy of this form to the defendant.

 The above statements are true to the best of my knowledge:

 

 

______________________________________________            __________________________

Signature and/or signature of legal guardian                             Date


 

 

 

List of Damaged and/or Stolen Property

 

 

 

                                                Date of           Purchase           Cost to

Item                                           Purchase         Price                 Replace Item

 

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

____________________________     ________________    ________________   ________________

 

Total:                                                 __________  _________

 

Please return this form and all supporting documents within 10 business days to:

 

Victim-Witness Unit

Monmouth County Prosecutor’s Office

132 Jerseyville Avenue

Freehold, NJ  07728-2374

 

If you have any questions, please call the Victim-Witness Unit 732-431-6459

Si ústed no entiende este formulario, y desea recibirlo en espanol, favor de llamar al numero 732-431-6459