This Victim Impact Statement (VIS) will be used throughout

thecriminaljusticesystem(bytheprosecutor,thejudge,and
the parole board) to better understand the emotional/
psychological,physical,andfinancialimpactofthecrime.

The contact information you provide in this Victim Impact

Statementisimportantandwillbeusedtocontactyouifyou
wishtoreceiveinformationfrom:

Community Supervision and Corrections Department

(probation);
TexasDepartmentofCriminalJustice(prison);and
BoardofPardonsandParoles.

Returnthe
ConfidentialVictimContactInformationandthe

VictimImpactStatementtothe

countyordistrictattorneysoffice

thatisprosecutingyourcase.

TOBECOMPLETEDBYTHEVICTIMASSISTANCECOORDINATOR
VictimAssistanceCoordinator:

Agency:

Address:

City:
ZipCode:

Phone:
Fax:

Email:

REMOVE AND KEEP FOR YOUR RECORDS

CRIMEVICTIMINFORMATIONSHEETANDVICTIMIMPACTSTATEMENTPACKET

ATENCIN:SiUd.requiereasistenciaenespaolotienepreguntassobreestedocumento,
favordellamaral______________________________.

KNOWYOURRIGHTSINTHECRIMINALJUSTICESYSTEM
1. CRIMEVICTIMSRIGHTS:Youhavecrimevictimrightsifyouarea:
Victim,
Parent/Guardianofavictim,or
Closerelativeofadeceasedvictim

2. CONFIDENTIALINFORMATIONSHEET:
Usedbycriminaljusticeprofessionalstocontactyouthroughouttheprocess.
Usedtoelectandexerciseyourrightstonotificationofcourtproceedings,probation,parole,andrelease.
Used by the Texas Department of Criminal Justice (TDCJ) to add you to their database if you request to receive
notificationofchangesinthedefendantsstatusifheorsheisincarceratedinaTDCJfacility(prison).
TheConfidentialInformationSheetcannotbeseenbythedefendantorthedefenseattorney.
You must notify your Victim Assistance Coordinator if any of your contact information changes to make sure
youarekeptinformed.IfthedefendantisconvictedandsenttoaTDCJfacility,notifytheTDCJVictimServices
Divisionofanynewcontactinformationat18008484284orvictim.svc@tdcj.state.tx.us.

3. VICTIM IMPACT STATEMENT: Victims have the right to submit a Victim Impact Statement. The Victim Impact
Statementisawritten,detailedaccountoftheemotional/psychological,physical,andfinancialimpactthecrimehad
on the victims and family members. This document can be used to explain your feelings such as loss, frustration,
fear,and/oranger.Onlyyoucanprovidethisvitalinformation.

KNOWHOWYOURVICTIMIMPACTSTATEMENTISUSED

Prosecutor:

ConsidersyourVictimImpactStatementbeforeenteringintoapleaarrangement.

ConsidersyourVictimImpactStatementtodeterminetherestitutionamount(ifrequested).

Judge:
Considers your Victim Impact Statement before imposing a sentence; the Victim Impact Statement is not
consideredbyajury.
ConsidersyourVictimImpactStatementbeforeacceptingtheplea.

Defense:
Your Victim Impact Statement, excluding the Confidential Information Sheet, may be seen by the defendant
andhisorherattorney.
The defendant or his or her attorney may comment on the Victim Impact Statement and, with approval of the
court,introduceevidenceortestimonyinregardstoitsaccuracy.

CommunitySupervision(Probation):
CommunitySupervisionofficershaveaccesstoyourVictimImpactStatementfornotificationpurposes.

TexasDepartmentofCriminalJustice:
Ifthedefendantissentencedtoprison,yourVictim ImpactStatement goestotheTDCJVictimServicesDivision
to provide you with information regarding the defendant. You can register for this service by completing the
ConfidentialInformationSheet,whichisapartoftheattachedVictimImpactStatement.

BoardofPardonsandParoles:
TheParoleBoardwillconsideryourVictimImpactStatementpriortovotingwhetherornottoreleasethe
offendertoparolesupervision.
REMOVE AND KEEP FOR YOUR RECORDS

Article56.01DEFINITIONS

(1) Close relative of a deceased victim means a person who

was the spouse of a deceased victim at the time of the victims
death or who is a parent or adult brother, sister, or child of the
deceasedvictim.
(2) Guardian of victim means a person who is the legal
guardian of the victim, whether or not the legal relationship
between the guardian and the victim exists because of the age
of the victim or the physical or mental incompetency of the
victim.
(2a) Sexual assault means an offense under Section 21.02,
21.11(a)(1),22.011,or22.021,PenalCode.
(3) Victim means a person who is the victim of the offense of
sexual assault, kidnapping, aggravated robbery, trafficking of
persons, or injury to a child, elderly individual, or disabled
individual or who has suffered personal injury or death as a
resultofthecriminalconductofanother.

information related to the costs that may be compensated

under that subchapter and the amount of compensation,
eligibility for compensation, and procedures for application
for compensation under that subchapter, the payment for a
medical examination under Article 56.06 for a victim of a
sexual assault, and when requested, to referral to available
socialserviceagenciesthatmayofferadditionalassistance;
(7)the right to be informed, upon request, of parole
procedures, to participate in the parole process, to be
notified, if requested, of parole proceedings concerning a
defendant in the victim's case, to provide to the Board of
Pardons and Paroles for inclusion in the defendant's file
information to be considered by the board prior to the
parole of any defendant convicted of any crime subject to
this subchapter, and to be notified, if requested, of the
defendant'srelease;
(8)the right to beprovidedwith a waitingarea, separateor
secure from other witnesses, including the offender and
Article56.02 CRIMEVICTIMSRIGHTS
relativesoftheoffender,beforetestifyinginanyproceeding

concerning the offender; if a separate waiting area is not

(a)Avictim,guardianofavictim,orcloserelativeofadeceased
available, other safeguards should be taken to minimize the
victim is entitled to the following rights within the criminal
victim's contact with the offender and the offender's
justicesystem:
relatives and witnesses, before and during court
(1)the right to receive from law enforcement agencies
proceedings;
adequate protection from harm and threats of harm arising
(9)the right to prompt return of any property of the victim
fromcooperationwithprosecutionefforts;
thatisheldbyalawenforcementagencyortheattorneyfor
(2)the right to have the magistrate take the safety of the
the state as evidence when the property is no longer
victimorhisfamilyintoconsiderationasanelementinfixing
requiredforthatpurpose;
theamountofbailfortheaccused;
(10)the right to have the attorney for the state notify the
(3)theright,ifrequested,tobeinformed:
employer of the victim, if requested, of the necessity of the
(A)by the attorney representing the state of relevant
victim's cooperation and testimony in a proceeding that
court proceedings, including appellate proceedings,
may necessitate the absence of the victim from work for
and to be informed if those proceedings have been
goodcause;
canceledorrescheduledpriortotheevent;and
(11)the right to request victimoffender mediation
(B)by an appellate court of decisions of the court,
coordinated by the victim services division of the Texas
after the decisions are entered but before the
DepartmentofCriminalJustice;
decisionsaremadepublic;
(12)the right to be informed of the uses of a victim impact
(4)the right to be informed, when requested, by a peace
statement and the statement's purpose in the criminal
officer concerning the defendant's right to bail and the
justice system, to complete the victim impact statement,
procedures in criminal investigations and by the district
andtohavethevictimimpactstatementconsidered:
attorney's office concerning the general procedures in the
(A)by the attorney representing the state and the
criminal justice system, including general procedures in
judge before sentencing or before a plea bargain
guilty plea negotiations and arrangements, restitution, and
agreementisaccepted;and
theappealsandparoleprocess;
(B)by the Board of Pardons and Paroles before an
(5)therighttoprovidepertinentinformationtoaprobation
inmateisreleasedonparole;
department conducting a presentencing investigation
(13)for a victim of an assault or sexual assault who is
concerning the impact of the offense on the victim and his
younger than 17 years of age or whose case involves family
family by testimony, written statement, or any other
violence, as defined by Section 71.004, Family Code, the
mannerpriortoanysentencingoftheoffender;
tohavethecourtconsidertheimpactonthevictimof
right
(6)the right to receive information regardingcompensation

requestedbythedefendant;ifrequestedby
a
continuance
tovictimsofcrimeasprovidedbySubchapterB,including

REMOVE AND KEEP FOR YOUR RECORDS

the attorney representing the state or by counsel for the

defendant,thecourtshallstateontherecordthereasonfor
grantingordenyingthecontinuance;and
(16)iftheoffenseisacapitalfelony,therightto:
(A) receive by mail from the court a written

explanation of defenseinitiated victim outreach if the

court has authorized expenditures for a defense
initiatedvictimoutreachspecialist;
(B) not be contacted by the victim outreach specialist
unless the victim, guardian, or relative has consented
to the contact by providing a written notice to the
court;and
(C) designate a victim service provider to receive all
communications from a victim outreach specialist
actingonbehalfofanyperson.
(b)Avictim,guardianofavictim,orcloserelativeofadeceased
victim is entitled to the right to be present at all public court
proceedings related to the offense, subject to the approval of
thejudgeinthecase.
(c)The office of the attorney representing the state, and the
sheriff,police,andotherlawenforcementagenciesshallensure
to the extent practicable that a victim, guardian of a victim, or
closerelativeofadeceasedvictimisaffordedtherightsgranted
by this article and Article 56.021 and, on request, an
explanationofthoserights.
(d)A judge, attorney for the state, peace officer, or law
enforcement agency is not liable for a failure or inability to
providearightenumeratedinthisarticleorArticle56.021.The
failure or inability of any person to provide a right or service
enumeratedinthisarticleor Article56.021maynotbeusedby
a defendant in a criminal case as a ground for appeal, a ground
tosetasidetheconvictionorsentence,oragroundinahabeas
corpus petition. A victim, guardian of a victim, or close relative
of a deceased victim does not have standing to participate as a
party in a criminal proceeding or to contest the disposition of
anycharge.

Note: During the 83rd Legislative Session, multiple bills were

passed which resulted in the current numbering of the
subsections. Therefore, the Texas Code of Criminal Procedure
Article56.02(a)(1415)currentlydonotexist.

regarding any evidence that was collected during the

investigation of the offense, unless disclosing the
information would interfere with the investigation or
prosecutionoftheoffense,inwhicheventthevictim,
guardian,orrelativeshallbeinformedoftheestimateddate
onwhichthatinformationisexpectedtobedisclosed;
(2)if requested, the right to a disclosure of information
regarding the status of any analysis being performed of any
evidence that was collected during the investigation of the
offense;
(3)ifrequested,therighttobenotified:
(A)at the time a request is submitted to a crime
laboratory to process and analyze any evidence that
wascollectedduringtheinvestigationoftheoffense;
(B)at the time of the submission of a request to
compare any biological evidence collected during the
investigation of the offense with DNA profiles
maintainedinastateorfederalDNAdatabase;and
(C)of the results of the comparison described by
Paragraph (B), unless disclosing the results would
interferewiththeinvestigationorprosecutionofthe
offense,inwhicheventthevictim,guardian,orrelative
shall be informed of the estimated date on which
thoseresultsareexpectedtobedisclosed;
(4)if requested, the right to counseling regarding acquired
immune deficiency syndrome (AIDS) and human
immunodeficiencyvirus(HIV)infection;
(5)for the victim of the offense, testing for acquired
immune
deficiency
syndrome
(AIDS),
human
immunodeficiencyvirus(HIV)infection,antibodiestoHIV,or
infection with any other probable causative agent of AIDS;
and
(6)to the extent provided by Articles 56.06 and 56.065, for
the victim of the offense, the right to a forensic medical
examinationif,within96hoursoftheoffense,theoffenseis
reported to a law enforcement agency or a forensic medical
examinationisotherwiseconductedatahealthcarefacility.
(b)A victim, guardian, or relative who requests to be notified
under Subsection (a)(3) must provide a current address and
phone number to the attorney representing the state and the
law enforcement agency that is investigating the offense. The
victim, guardian, or relative must inform the attorney
representing the state and the law enforcement agency of any
Art.56.021RIGHTSOFVICTIMOFSEXUALASSAULT
changeintheaddressorphonenumber.

(c)A victim, guardian, or relative may designate a person,

(a)In addition to the rights enumerated in Article 56.02, if the
including an entity that provides services to victims of sexual
offense is a sexual assault, the victim, guardian of a victim, or
assault, to receive any notice requested under Subsection
close relative of a deceased victim is entitled to the following
(a)(3).
rightswithinthecriminaljusticesystem:

(1)ifrequested,therighttoadisclosureofinformation

YOUR RECORDS

REMOVE AND KEEP FOR

ENTIAL
C ONFID

INFORMATION
VICTIMCONTACT

CONFIDENTIALINFORMATIONSHEET

ThisConfidentialInformationSheetwillbeusedbycriminaljusticeprofessionalstocontactyouthroughouttheprocess.Thisincludes
notifyingyouaboutcourtproceedings,communitysupervision(probation),andparoleorreleaseifthedefendantissenttoprison.

You may choose to complete only this page for notification purposes.
ATENCIN:SiUd.requiereasistenciaenespaolotienepreguntassobreestedocumentofavordellamaral___________________.

TOBECOMPLETEDBYTHEVICTIMASSISTANCECOORDINATOR
OFFENSE:
DEFENDANT(S)NAME(LAST,FIRSTMI)

DPSStateID(SID)

DOB (mm/dd/yyyy)

OFFENSEDATE:
Cause/Case#

Court#

TDCJ#

SECTIONS1&2TOBECOMPLETEDBYVICTIM,PARENT/GUARDIANORCLOSERELATIVE
SECTION1.NOTIFICATION
Doyouwanttobenotifiedaboutrelevantcourtproceedings?

YES

NO

Doyouwanttobenotifiedifthedefendantisplacedoncommunitysupervision(probation)?
Ifthedefendantissenttoprison(TexasDepartmentofCriminalJustice),doyouwanttobenotifiedwhenheor
sheisbeingconsideredforparoleorrelease?
Ifthedefendantissenttoprison,doyouwantthedefendanttobeprohibitedfromcontactingyou?

YES

NO

YES

NO

YES

NO

IMPORTANT!

IFYOUMOVEORCHANGEANYOFYOURCONTACTINFORMATION,CALLYOURVICTIMASSISTANCECOORDINATOR

ORTHETEXASDEPARTMENTOFCRIMINALJUSTICEVICTIMSERVICESDIVISIONAT8008484284.

SECTION2.CONFIDENTIALINFORMATION(Pleaseuseblackinkandprintclearly)
DriversLicenseNo.andState:
VictimsName:
DateofBirth:

Male

NameofPersonSubmittingthisStatement:

Female

DriversLicenseNo.andState:

Address:

City:

State:

HomePhone:

WorkPhone:

EmailAddress:

DateofBirth:

Zip:

CellPhone:
RelationshiptoVictim:

Pleaseprovidethecontactinformationofsomeonenotlivingwithyouwhowillknowhowtocontactyou.
FullName:

Address:

City:

State:

HomePhone:

EmailAddress:

WorkPhone:

Zip:

RETURN TO YOUR

VICTIM ASSISTANCE COORDINATOR

CellPhone:

RelationshiptoVictim:

VICTIMIMPACTSTATEMENT

TheVictimImpactStatement(VIS)willbeusedthroughoutthecriminaljusticesystembytheprosecutor,thejudge,
andtheparoleboardtobetterunderstandtheemotional/psychological,physical,andfinancialimpactofthecrime.
TOBECOMPLETEDBYTHEVICTIMASSISTANCECOORDINATOR
OFFENSE:

OFFENSEDATE:

DEFENDANT(s)NAME(LAST,FIRSTMI)

DPSStateID(SID)

DOB(mm/dd/yyyy)

Cause/Case#

Court#

TDCJ#

Pleasegiveinformationyoubelieveisimportantabouttheeffectofthiscrimeonyouandyourfamily.
Pleasedonotrelateanyinformationaboutthecrimeitself;thosefactsareavailableinotherreports.

The information in this statement will show the impact the crime has on the victim, the parents, guardians or close
relatives of the victim or other family members of the victim. It may be used at each phase of the criminal justice
process: from the prosecution of the offense; to sentencing to community supervision or to incarceration in the Texas
Department of Criminal Justice; and through the parole review process. Please answer only as many questions as you
wish.Ifyouneedmorespace,anadditionalpageisavailable;attachittothisVictimImpactStatement.

TOBECOMPLETEDBYTHEVICTIM,PARENT/GUARDIANORCLOSERELATIVEOFTHEVICTIM

VictimsName:

EMOTIONAL/PSYCHOLOGICAL IMPACT. Use this section to discuss your feelings about what has happened to you as a
resultofthecrimeandhowithasaffectedyourgeneralwellbeing.Pleasecheckallthereactionsyouhaveexperienced.

Changesinsleeppattern
Lackofconcentration Fearofstrangers
Lossofsecurity/control
Nightmares
Fearofbeingalone
Anger
Feelingsofhelplessness
Difficultytrustingothers
Anxiety
Crymoreeasily
Fearofleavinghome
Changeinappetite
Jobstress
Familynotasclose
Other

Depression
Wanttobealone
Schoolstress

Marital/Relationshipproblems

Hasthevictimorthevictimsfamilysoughtcounselingasaresultofthecrime?
Yes
No

Howhasthiscrimeaffectedyou,yourfamilyorthoseclosetoyou?Pleasefeelfreetodiscussyourfeelings,thoughts,
andgeneralwellbeing.(Pleaseattachadditionalpageifused.)

RETURN TO YOUR

VICTIM ASSISTANCE COORDINATOR


PHYSICAL INJURY. Use this section to discuss any physical injuries suffered as a result of this crime. You may want to
writeabouttheextentoftheinjuriesandhowlongtheinjurieslasted.(Pleaseattachadditionalpageifused.)

Treatedat____________________________________(medicalcenter/clinic/physiciansoffice)
Hospitalizedat_______________________________________for____days

FINANCIALLOSS.
Losses you have incurred may include medical and dental care, emergency transportation, property loss or damages,
lossofincomefromwork,counseling,crimescenecleanup,movingorchangingresidence,funeralcosts,andothercosts
ofthisnature.

You may want to begin keeping a log of your financial loss as soon as possible after the crime occurred. You may also
want to keep any receipts and records you have in a folder or separate location for safe keeping. In the event of a
conviction,theprosecutororjudgemayusethisinformationtodetermineifanyrestitutionmaybeordered.

Pleaseprovideabestestimateofyourfinanciallosstodate:

Doyouanticipateanyfuturecostsresultingfromthiscrime?

Yes

No

Wereanyexpensescoveredbyinsuranceorothersources?

Yes

No

HaveyouappliedforCrimeVictimsCompensationthroughtheAttorneyGeneralsOffice?

Yes

No

Ifyouhavenot,youmayapplyatwww.texasattorneygeneral.govorcall18009839933.

TheinformationinthisVictimImpactStatementistrueandcorrecttothebestofmyknowledge.

____________________________________________

PrintName

____________________________________________
_________________________

Signature
Date

INFORMATIONSUBMITTEDBY:Victim Parent/GuardianCloseRelativeOther_________________

RETURN TO YOUR

VICTIM ASSISTANCE COORDINATOR