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, the State Board of Pardons and Paroles, and 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 a family member to serve as the point of contact.
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OFFENDER INFORMATION
Name of Offender *
Date of Birth of Offender
MM
/
DD
/
YYYY
Gender of the Offender *
Offense
Conviction Date
MM
/
DD
/
YYYY
County of Conviction
Indictment Number
(if known)
GDC ID or Case Number
(if known)
VICTIM INFORMATION
Name of Victim *
Person Requesting Notification
(If different from victim)
Person completing form relationship to victim *
Reason victim did not complete form
(i.e deceased, minor, etc)
Registrant mailing Address *
(Street # and name / P.O.Box #)                                                                
City *
State *
If you clicked on INTERNATIONAL please list the address below
Zip Code *
Primary Telephone Number
(numbers only, no special characters, i.e 4046516668)
Type of Primary Phone *
Secondary Telephone Number
(numbers only, no special characters, i.e 4046516668)
Type of Secondary Phone
Email Address
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)
If you require special accommodations in accordance with the Americans with Disabilities Act, please list below
(Americans with Disabilities Act (ADA))
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