Last updated: 11/8/2010
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. WHITFIELD COUNTY JUVENILE COURT : JUDICIAL SUBPOENA VICTIM IMPACT STATEMENT Plaintiff(s) SEND THE COMPLETED FORM TO: Whitfield County Juvenile Court County Courthouse Annex 301 W. Crawford Street Dalton, Ga. 30720 Case No: Court Officer: Offense: -against- : : : Defendant(s) Offense Date: : ...................................................... Georgia law provides that in appropriate cases, children, who by their behavior have caused others to suffer economic loss, can be ordered to compensate their victims. It is the policy of this Court, in appropriate cases, PEOPLE OF restitution OF NEW YORK the treatment and rehabilitation of the to order THE STATE consistent with child. The information you provide may help the District Attorney, Judge and Court Staff better understand how the child's behavior has affected you and your family. Attach more sheets if necessary. If this statement is considered by the Judge before a dispositional hearing, it will also be given to the child's attorney. THE TO GREETINGS: Person attend before , the located at County of 1. Briefly tell about the offense that was committed against you (or your family member). in room , on the day of , 20 , at o'clock in the noon, and at _____________________________________________________________________________________________________ any recessed _____________________________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 2. Were you physically injured because of this offense? _________ If yes, tell the kind of injury and the amount of injury. Tell how serious it was. Tell how long the injury last or will last. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Victim's Name ___________________________________ other than Victim completing this Statement _____________________________ Relation of Victim (family member or attorney) ___________________________ StreetCOMMAND YOU, that all business and excuses being laid aside, you and each of you WE Address _________________________________________________________________ City, State, Zip Code __________________________________________________________ Honorable Phone Numbers __________________________________________________________ at the Court Contact Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, 3. Was medical treatment needed for your physical injury? ______ I yes, tell about the treatment. Tell how long the treatment was or will be needed? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _________________ , one of the Justices of the day of , 20 4. Were you or your family psychologically (emotionally) injured because of this offense? ______ If yes, tell how this injury has affected your or your family. (Psychological injury may include change in attitude or feelings, fear, change in lifestyle, emotional problems, et.) _____________________________________________________________________________________________________ (Attorney must sign above and type name below) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. Have you or your family received counseling or therapy because of this offense? ______ If yes, tell how long you or your family member have received counseling or therapy. __________________________________________________________________________________________________ Attorney(s) for 1 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : : : : Index No. Calendar No. 6. Has this offense affected your ability to earn a living? ______ If yes, tell how. Mention any days lost from work. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ JUDICIAL SUBPOENA -against- 7. Has this offense in any way affected your family relationships? _____ If yes, explain. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 8. Have you had any expense or economic loss because of this offense? ______ If yes, use the columns below to list them. See page 2 for additional information. Defendant(s) : E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XP.ENSE.S. . . . . . . . . . . KIND OF EXPENSE Medical/Hospital Treatment, Counseling, Other _____________________________________________ ________