Victim Profile Form printable pdf download

Please fill out and return at your earliest convenience.

Our File # __________________

Defendant _________________

VICTIM PROFILE FORM

Name __________________________________

Sex __________

Address ________________________________

Race _________

City _____________________ Zip ___________

Age __________

Home Phone ____________________________

Marital Status _______________

Employed at ______________________ Employed at __________________________

Hours ______________ to ______________

Phone ____________________

Business Phone ____________________

Name and Phone of Close Friend or Relative _________________________________

Type of Crime _________________________________________________________

Date _________________________________

Location ______________________________

Offender Known to Victim? Yes ______ No ______

Relationship ____________________________

Any Injury? Yes ____ No _____Specify ___________________________________

Ambulance Service?

Yes ____ No ______ Hospital____________________

Medical Follow-up Necessary? Yes ____ No ______ Physician __________________

PROPERTY LOSS NOT RECOVERED BY POLICE* Dollar Amount $_____________

Specify _________________________________________________________

Rental Property: Yes______ No ______ Landlord ____________________________

Address _________________________ Telephone ___________________________

Loss Covered by Insurance?

Yes ______ No ______

Insurance Company: ________________________ Deductible ____________

Address: __________________________________

__________________________________ Telephone ____________

Claim Adjuster _____________________________

* IF PROPERTY LOSS IS INDICATED, PLEASE ATTACH ALL COPIES OF BILLS,

RECEIPTS OR ESTIMATES REGARDING LOSS.

Any health problems we should be aware of?

____________________________________________________________________

Any plans or commitments to be out of town in the near future?

_____________________________________________________________________

Victim Profile Form