OFFICE USE ONLY: Prisoner Number: ERD: Location:
MICHIGAN DEPARTMENT OF CORRECTIONS
CRIME VICTIM NOTIFICATION REQUEST FORM
(Please Print)
This form should be forwarded to the Department of Corrections AFTER
the defendant has been sentenced to prison. Once
the MDOC has received the defendant and your request, we will send you a letter acknowledging the receipt of your
notification request. Please contact the Crime Victim Notification Unit should you have any questions from 8:00 a.m. to 5:00
p.m. Monday through Friday. In addition, you may also access our web site 24 hours at www.michigan.gov/corrections
to
retrieve additional information.
Please mail your request to:
MICHIGAN DEPARTMENT OF CORRECTIONS
CRIME VICTIM NOTIFICATION UNIT
P.O. BOX 30003
LANSING, MI 48909
(517) 373-4467 LOCAL, (877) 886-5401 TOLL-FREE
INMATE INFORMATION
: Please provide as much information as possible. A separate notification form for each inmate/offender.
Inmate Name: Last, First, M. Inmate #:
D.O.B. Soc. Sec. #: Race: Sex:
Court Case #: Sentencing County: Sentencing Date:
Offense Convicted of:
In order for us to appropriately determine if you qualify under the Crime Victim’s Rights Act, please complete the information below:
Is the Victim Deceased? Yes No Is the Victim a Minor? Yes No
VICTIM INFORMATION: The victim or a designated representative may receive notification. If a designated representative is chosen,
he or she must complete and sign this form.
Victim Name: Last, First, M.:
Person requesting notification, if other than victim:
If other than victim, please state relationship to victim:
Please list your relationship to the defendant:
Address: City: State:
Zip Code: **Primary Phone: ( ) **Secondary Phone: ( )
** It is imperative we have a phone number to contact you in the event of an unanticipated release. We will need to speak
with someone directly, therefore, please do not
indicate any pager numbers/extension numbers. You will automatically be
registered to receive automated notification through M.C.V.N.N. (Michigan Crime Victim Notification Network).
My signature below indicates that I am requesting notification under the Crime Victim Rights Act. I understand that it is my
responsibility to notify the Crime Victim Notification Unit in writing of any changes in my name, address, and/or phone numbers.
Are you currently being threatened by the defendant?
Yes
No
Do you currently have a Personal Protection Order?
Yes
No
Victim/Requestor’s Signature: Date:
CONFIDENTIAL AND EXEMPT UNDER FREEDOM OF INFORMATION ACT
