Victim Impact Statement
This form should be completed after the offender has been sentenced and remanded to the custody of the Georgia Department of Corrections. Your Victim Impact Statement will become a permanent and confidential part of the offender’s file.

For more information, please contact the Georgia Office of Victim Services:
At 1-800-593-9474, 404-651-6668, victimservices@pap.ga.gov or visit our website at http://www.pap.ga.gov.

Once registered, you will receive information and notifications regarding the offender's status with the Department of Corrections, clemency decisions made by the State Board of Pardons and Paroles, and can make inquiries regarding the offender under the authority of the Department of Community Supervision.

If you are currently registered, it is your responsibility to notify the Georgia Office of Victim Services of changes to your postal mail, email, and telephone numbers. Please submit a change of address form (click here---> https://forms.gle/D2FFn8X3RM783qwQ7) to update your contact information.

* In the event of multiple inquiries within the same family, the Director of the Georgia Office of Victim Services has the discretion to appoint one family member to serve as the point of contact.
OFFENDER INFORMATION
Offender Name *
Your answer
Offender Date of Birth
MM
/
DD
/
YYYY
Offender Gender *
Offense
Your answer
Conviction Date
MM
/
DD
/
YYYY
County of Conviction
Indictment Number
(if known)
Your answer
Offender GDC ID or Case Number
(if known)
Your answer
VICTIM INFORMATION
Victim Name *
Your answer
Person Requesting Notification
(If different from victim)
Your answer
Person completing form relationship to victim *
Reason victim did not complete form
(i.e deceased, minor, etc)
Your answer
Registrant mailing Address *
(Street # and name / P.O.Box #)
Your answer
City *
Your answer
State *
If you clicked on INTERNATIONAL please list the address below
Your answer
Zip Code *
Your answer
Primary Telephone Number
Your answer
Type of Primary Phone *
Secondary Telephone Number
Your answer
Email Address
Your answer
Please explain how this crime has affected you and/or your family members. Include all information you want taken into consideration by the Parole Board *
(Unlimited space provided for response)
Your answer
If you require special accommodations in accordance with the Americans with Disabilities Act, please list below
(Americans with Disabilities Act (ADA))
Your answer
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