Office of the State Attorney
10th Judicial Circuit
State Attorney Brian Haas
Serving Polk, Highlands, and Hardee Counties

Victim Impact Statement
This is a statement made either verbally or in writing to the Court before sentence is imposed. In the statement, the victim may describe the effect the crime has had on his or her family and the emotional and financial losses that he or she may have suffered. If you have questions or need assistance in preparing a Victim Impact Statement, a Victim Advocate will be available to assist you. Please call (863)534-4800 for assistance.

This form can be printed, then completed with the requested information. The Victim Impact Statement form must be notarized and mailed to this address:

Office of the State Attorney, 10th Circuit
Drawer SA, P.O. Box 9000
Bartow, FL 33831-9000

Victim Impact Statement word document

Victim Impact Statement pdf document