STATE BOARD OF PARDONS AND PAROLES
Victim Change of Address Form



Persons who have previously completed a Victim Impact Statement, Notification Request Form or written a letter whose mailing address has changed should complete the information below.

INMATE INFORMATION

Inmate Name:
I.D.#
County of Conviction:
Sentence Date:
Offense(s)

(If you do not know the inmate's I.D.#, please provide DOB, SS#, gender, as listed below.)
Date of Birth:
SS#:
Gender:
Male
Female

VICTIM INFORMATION
Victim Name:
Date of Birth:
Person Requesting notification (if other than victim):
Relationship to Victim:
PREVIOUS
Mailing Address:
City:
State:
Zip:
Phone Nbr:
Email Address:
NEW
Mailing Address:
City:
State:
Zip:
Your Home
Phone Nbr:
Your Work
Phone Nbr:
Your Cell
Phone Nbr:
Your Email
Address: