STATE BOARD OF PARDONS AND PAROLES
Victim Impact Statement
** To be completed by a victim or for a victim by a family member or attorney**

INMATE INFORMATION
Defendent's Name:
Case Number
(if known)
County of Conviction:
Sentence Date:
Offense(s)

(If you do not know the inmate's Case Number, please provide DOB, Gender as listed below.)
Date of Birth:
Gender:
 Male
Female
VICTIM INFORMATION
The information provided below may help the Parole Board better understand how this crime has affected you and your family. If the Defendant enters a state prison, you can mail this statement to the Parole Board’s Office of Victim Services, 2 Martin Luther King, Jr. Drive, S.E., Atlanta, Georgia 30334. Your Impact Statement will become a permanent and strictly confidential part of the Parole Board’s case file on the inmate. By completing the Impact Statement you automatically receive early notification of any parole consideration. This allows you the opportunity to voice your opinion about the possible parole of the inmate. In the event of multiple inquiries within the same family, the Director of the Office of Victim Services has the discretion to appoint one family member to serve as the point of contact.

For more information, please contact the Parole Board’s Office of Victim Services: 1) toll-free at 1-800-593-9474,
2) locally at 404-651-6668 or, 3) visit our website at www.pap.state.ga.us.
It is your responsibility to notify the Parole Board of any mailing address, email or telephone changes.

Victim Name:
Date of Birth:

Person other than victim completing statement:
Relationship to Victim:
Reason Victim did not complete statement:
Mailing Address of statement writer:
City:
State:
Zip:
Home Phone #: Email Address:

Work Phone #: Cell Phone #:

Please explain how this crime has affected you (or family member). Include all information and concerns you want taken into consideration by the Parole Board.