We are sorry to learn that you or a member of your family was the victim of a crime. We would like to provide you with assistance as your case is processed through the criminal justice system.
Enclosed with this letter are several forms.  We ask that you complete the forms and return them to our office as soon as possible. 
•	You have the right to be notified of court proceedings and hearings and to be present at those events.  If you would like us to notify you, please note your contact information on the enclosed Victim Notification form and return it to us.
•	If you would like to make a statement to the Judge about how this crime has affected your life, complete and return the Victim Impact Statement.
PLEASE NOTE:  THIS STATEMENT IS SUBJECT TO PUBLIC RECORD DISCLOSURE UNDER STATE LAW.
•	If you suffered a monetary loss as a result of this crime, complete the Restitution Estimate. Losses must be verified with bills, receipts, estimates, or explanations of the loss.  If you did not suffer a monetary loss, please note that on the Restitution Estimate.
•	If you have insurance coverage, please give the Form for Your Insurance Company to your provider.
•	If you are the victim of a personal injury crime, you may be eligible for Crime Victims Compensation from the State of Washington.  If so, go to the website,   www.CrimeVictims.Lni.wa.gov and click on Forms & Publications for Crime Victims then enter F800-042-000 for the application. 

We understand that you may have questions about some or all of the enclosed.  Please don’t hesitate to call or email our office for further assistance.  The Vancouver City Attorney’s Office is located at 415 W 6th Street, Vancouver, Washington. 360-487-8500. City.attorneyemails@cityofvancouver.us . 
Enclosures
*****PLEASE RETAIN THIS PAGE FOR YOUR RECORDS******VICTIM IMPACT STATEMENT

Victim name:		

Defendant Name: 

Case Number:	

 I or another representative or family member would like to address the court at sentencing
Please use this form to make a brief statement to the court (preferably typed) about the emotional, financial, medical and/or social impact this offense has had upon you.  PLEASE NOTE: THIS STATEMENT IS SUBJECT TO PUBLIC RECORD DISCLOSURE UNDER STATE LAW.

		

		

		

		

Please do not write on the back of this form.  Use additional pages if necessary.		
__________________________________________________
Signature	_____________________________
Date	

Please return your completed form to:

Vancouver City Attorney’s Office
Domestic Violence Prosecution Center
PO Box 1995
Vancouver WA 98668-1995

City.attorneyemails@cityofvancouver.us VICTIM NOTIFICATION

Defendant(s): 

Case Number:

I would like to receive notification of		Trial	I would like to attend		Trial	
		Change Of Plea			Change Of Plea	
		Sentencing			Sentencing	
You have the right to testify at sentencing regarding the impact this crime has had on you.						
Impact Statement		I or another representative or family member would like to address the court at sentencing				
Your Contact Information						
Name						
Business						
Address						
City, State, Zip						
Home Phone	Work Phone	Cell Phone	E-mail Address			

Please let us know the best way to contact you by checking one of the boxes below
Home Phone		Cell Phone		Work Phone		
Email		Mail		Other 		

Please return your completed form to:

Vancouver City Attorney’s Office
Domestic Violence Prosecution Center
PO Box 1995
Vancouver WA 98668-1995
City.attorneyemails@cityofvancouver.us 

	RESTITUTION ESTIMATE	VICTIM NAME					
		ADDRESS					
DEFENDANT(S)	CITY, STATE, ZIP						
	Case No. 	HOME PHONE		WORK PHONE			
PLEASE NOTIFY THIS OFFICE OF ANY CHANGE OF ADDRESS OR PHONE NUMBER SO RESTITUTION PAYMENTS WILL REACH YOU
If you had no loss, please check  and return 							
PROPERTY LOSS OR DAMAGE	DESCRIPTION OF ITEM
(Include Branch Name, Model No. etc.)	ACTUAL REPAIR COST OR ESTIMATE	PURCHASE DATE	PURCHASE PRICE	AMOUNT INS. PAID	AMOUNT OF LOSS	

							

							
MEDICAL EXPENSES	DATE OF TREATMENT	TYPE OF TREATMENT (x-ray, er, counseling, etc.)	PHYSICIAN AND/OR HOSPITAL	COST			

							

INSURANCE	Was any of your loss covered by insurance?  	 No  	 Yes	Paid by insurance $_____________ 	Deductible $____________						
	insurance company	street address	city, state, zip	phone			
							
	policy number: 	claim number:		COMPANY REPRESENTATIVE: 				
TIME LOSS	If you lost time from work due to this incident, please attach a letter from your employer that states your hourly wage, the actual time lost and the total wage loss.  Include a letter from your physician providing a release to return to work date.						

I DECLARE, UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF WASHINGTON, THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT IF MY CLAIM IS DISPUTED, I WILL BE RESPONSIBLE FOR VERIFYING MY LOSSES TO THE COURT.

Signature _______________________________________________________________		Date: ____________________________________________

Please complete this form and return it to: Vancouver City Attorney’s Office
Domestic Violence Prosecution Center
PO Box 1995
Vancouver WA 98668-1995
City.attorneyemails@cityofvancouver.us 
 Include copies of bills, receipts or repair estimates. Please do not include items recovered or held in police evidence.

FORM FOR YOUR INSURANCE COMPANY

RE:   City of Vancouver v.

Case Number:	

TO:	Insurance Agency

Your insured has been a victim of a crime, and in order to obtain an accurate restitution figure, you must fill out the following information.  Failure to return this form will result in no restitution being ordered to your company.

Insured’s name: _____________________________________________________________		
Insured’s claim number: ______________________________________________________		
Insurance payment on this claim (Documentation is required, please submit)	$____________________________	
What is the insured’s deductible?	$____________________________	
Amount of any salvage value/recovered property value	$____________________________	
Name and telephone number of the responsible adjuster for any questions. 		
Address where payments should be paid in the event that restitution is ordered. 		

We appreciate your cooperation in filling out this form.  Please return it to the address below within fifteen days of its receipt.  If you have any questions, please call 360-487-8500.

Please return your completed form to:

Vancouver City Attorney’s Office
Domestic Violence Prosecution Center
PO Box 1995
Vancouver WA 98668-1995
City.attorneyemails@cityofvancouver.us