Fillable N E O M U Q S R (County of Erie)

Fill Online, Printable, Fillable, Blank N E O M U Q S R (County of Erie) Form

Use Fill to complete blank online COUNTY OF ERIE (PA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

N E O M U Q S R (County of Erie)

On average this form takes 19 minutes to complete

The N E O M U Q S R (County of Erie) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 75 other fields

Country of origin: US
File type: PDF

U.S.A. forms for County of Erie

BROWSE COUNTY OF ERIE (PA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
N
N
O
O
T
T
I
I
F
F
I
I
C
C
A
A
T
T
I
I
O
O
N
N
R
R
E
E
Q
Q
U
U
E
E
S
S
T
T
F
F
O
O
R
R
M
M
By checking the following statements you will be notified of those changes in case status. If you do not complete this
section you will NOT be contacted by the Erie County District Attorney’s Office about any changes in your case (Adult
Defendant). Please note VICTIMS of Juvenile Offenders are notified automatically of all requests listed below.
I REQUEST:
________ To be notified if a plea/adjudication is offered.
________ To be notified of the day, time and place of sentencing/disposition.
________ To be notified
o
o
f
f
t
t
h
h
e
e
o
o
u
u
t
t
c
c
o
o
m
m
e
e
o
o
f
f
t
t
h
h
e
e
s
s
e
e
n
n
t
t
e
e
n
n
c
c
e
e
/
/
d
d
i
i
s
s
p
p
o
o
s
s
i
i
t
t
i
i
o
o
n
n
.
.
________ Upon request to be notified if the defendant is released from custody at the time of sentencing/disposition.
________ To be notified of any reconsideration
o
o
f
f
s
s
e
e
n
n
t
t
e
e
n
n
c
c
e
e
/
/
d
d
i
i
s
s
p
p
o
o
s
s
i
i
t
t
i
i
o
o
n
n
granted by the court
.
.
(
(
W
W
h
h
i
i
c
c
h
h
m
m
a
a
y
y
i
i
n
n
c
c
l
l
u
u
d
d
e
e
e
e
s
s
c
c
a
a
p
p
e
e
,
,
r
r
u
u
n
n
a
a
w
w
a
a
y
y
,
,
a
a
b
b
s
s
c
c
o
o
n
n
d
d
e
e
r
r
.
.
)
)
A
A
L
L
L
L
P
P
E
E
R
R
S
S
O
O
N
N
A
A
L
L
I
I
N
N
F
F
O
O
R
R
M
M
A
A
T
T
I
I
O
O
N
N
W
W
I
I
L
L
L
L
B
B
E
E
K
K
E
E
P
P
T
T
C
C
O
O
N
N
F
F
I
I
D
D
E
E
N
N
T
T
I
I
A
A
L
L
A
A
N
N
D
D
I
I
S
S
S
S
T
T
R
R
I
I
C
C
T
T
L
L
Y
Y
F
F
O
O
R
R
L
L
A
A
W
W
E
E
N
N
F
F
O
O
R
R
C
C
E
E
M
M
E
E
N
N
T
T
U
U
S
S
E
E
O
O
N
N
L
L
Y
Y
.
.
IF YOU HAVE ANY CHANGE(S) IN YOUR HOME ADDRESS, OR PHONE
NUMBER(S), YOU MUST NOTIFY
T
T
H
H
E
E
R
R
E
E
S
S
T
T
I
I
T
T
U
U
T
T
I
I
O
O
N
N
/
/
V
V
I
I
C
C
T
T
I
I
M
M
A
A
D
D
V
V
O
O
C
C
A
A
T
T
E
E
S
S
,
,
I
I
M
M
M
M
E
E
D
D
I
I
A
A
T
T
E
E
L
L
Y
Y
,
,
B
B
Y
Y
C
C
O
O
N
N
T
T
A
A
C
C
T
T
I
I
N
N
G
G
:
:
A
A
D
D
U
U
L
L
T
T
M
M
A
A
T
T
T
T
E
E
R
R
S
S
:
:
(
(
8
8
1
1
4
4
)
)
4
4
5
5
5
5
-
-
9
9
5
5
1
1
5
5
: 125 W 18
TH
ST., ERIE, PA 16501
J
J
U
U
V
V
E
E
N
N
I
I
L
L
E
E
M
M
A
A
T
T
T
T
E
E
R
R
S
S
:
:
(814) 451.7018 or (814) 451-7496: 140 W 6
th
St. ERIE, PA 16501, ROOM 401
IF BUSINESS INDICATE NAME:________________________________________________
V
V
I
I
C
C
T
T
I
I
M
M
N
N
A
A
M
M
E
E
:
:
____________________________________________________________________________
A
A
D
D
D
D
R
R
E
E
S
S
S
S
:
:
_______________________________________________________________________________
C
C
I
I
T
T
Y
Y
:
:
__________________________________
S
S
T
T
A
A
T
T
E
E
:
:
___________
Z
Z
I
I
P
P
C
C
O
O
D
D
E
E
:
:
___________________
H
H
O
O
M
M
E
E
P
P
H
H
O
O
N
N
E
E
:
:
____________________
C
C
E
E
L
L
L
L
:
:
_____________________
W
W
O
O
R
R
K
K
:
:
__________________
S
S
O
O
C
C
I
I
A
A
L
L
S
S
E
E
C
C
U
U
R
R
I
I
T
T
Y
Y
N
N
O
O
.
.
:
:
XXX-XX-_______
D
D
A
A
T
T
E
E
O
O
F
F
B
B
I
I
R
R
T
T
H
H
:
:
________________________
(Optional) MM/DD/YYYY
JUVENILE CO-DEFENDANT: YES______ NO______
IF YES NAME(S):______________________________________________________________________
ADULT CO-DEFENDANT: YES______ NO______
IF YES NAME(S): ______________________________________________________________________
IF ADULT OFFENDER DO YOU APPROVE OF WORK RELEASE: YES______ NO______
IF NO PLEASE INDICATE REASONING ON ATTACHED FORM.
DEFENDANT: ____________________________________________ DOCKET NUMBER: __________________
R
R
E
E
S
S
T
T
I
I
T
T
U
U
T
T
I
I
O
O
N
N
C
C
L
L
A
A
I
I
M
M
F
F
O
O
R
R
M
M
E
E
R
R
I
I
E
E
C
C
O
O
U
U
N
N
T
T
Y
Y
D
D
E
E
P
P
A
A
R
R
T
T
M
M
E
E
N
N
T
T
S
S
O
O
F
F
P
P
R
R
O
O
B
B
A
A
T
T
I
I
O
O
N
N
/
/
P
P
A
A
R
R
O
O
L
L
E
E
If you suffered a financial loss due to this crime/delinquency the Judge can order the defendant to pay you back. In order
for the court to know how much money you are owed you must complete this form. THE ERIE COUNTY PROBATION &
PAROLE DEPARTMENTS
C
C
A
A
N
N
N
N
O
O
T
T
COLLECT YOUR MONEY IF YOU DO NOT COMPLETE THIS FORM INDICATING
A SPECIFIC DOLLAR AMOUNT OF REQUESTED RESTITUTION & PROVIDING APPROPRIATE DOCUMENTATION.
DEFENDANT: ____________________________________________________________________________________
DOCKET NUMBER: _________________________
VICTIM’S NAME AND ADDRESS: __________________________________________________________________
__________________________________________________________________
WAS LOSS COVERED BY INSURANCE? (PLEASE CIRCLE ONE) YES NO IN PART
DID YOU PAY A DEDUCTIBLE YES NO IF YES $__________________
IF YOUR ANSWER WAS “YES” OR “IN PART” YOU MUST COMPLETE THE FOLLOWING INFORMATION:
AMOUNT OF CLAIM
P
P
A
A
I
I
D
D
BY THE INSURANCE COMPANY $________________________
NAME AND ADDRESS OF INSURANCE COMPANY:
_______________________________________________________________________________ CLAIM # :_______________________
_______________________________________________________________________________ PHONE NUMBER:_________________
NAME OF POLICY HOLDER: ______________________________________________________ POLICY # :_______________________
Y
Y
O
O
U
U
R
R
O
O
U
U
T
T
-
-
O
O
F
F
-
-
P
P
O
O
C
C
K
K
E
E
T
T
L
L
O
O
S
S
S
S
(
(
L
L
O
O
S
S
S
S
T
T
H
H
A
A
T
T
W
W
A
A
S
S
N
N
O
O
T
T
R
R
E
E
I
I
M
M
B
B
U
U
R
R
S
S
E
E
D
D
B
B
Y
Y
I
I
N
N
S
S
U
U
R
R
A
A
N
N
C
C
E
E
,
,
E
E
M
M
P
P
L
L
O
O
Y
Y
E
E
R
R
S
S
,
,
E
E
T
T
C
C
.
.
)
)
:
:
LIST ANY/ALL OUT-OF-POCKET EXPENSES AS A RESULT OF THIS CRIME.
LIST ANY MEDICAL EXPENSES NOT COVERED BY INSURANCE THAT WERE INCURRED AS A RESULT OF THIS CRIME.
ATTACH PHOTOCOPIES OF BILLS AND RECEIPTS TO SUBSTANTIATE YOUR CLAIM.
WAS VICTIM COMPENSATION FILED/RECEIVED IF YES PLEASE INDICATE CLAIM AMOUNT.
______________________________________________________________________________ $________________________
______________________________________________________________________________ $________________________
______________________________________________________________________________ $________________________
______________________________________________________________________________ $________________________
______________________________________________________________________________ $________________________
(IF ADDITIONAL SPACE IS NEEDED, PLEASE USE BACK OF THIS FORM)
T
T
O
O
T
T
A
A
L
L
A
A
M
M
O
O
U
U
N
N
T
T
O
O
F
F
Y
Y
O
O
U
U
R
R
O
O
U
U
T
T
-
-
O
O
F
F
-
-
P
P
O
O
C
C
K
K
E
E
T
T
L
L
O
O
S
S
S
S
: $________________________
PLEASE PROVIDE THE NAME & CONTACT INFORMATION OF A BENEFICIARY SHOULD YOU BECOME DECEASED:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
NOTE: ANY INFORMATION GIVEN FALSELY MAY SUBJECT YOU TO A POSSIBLE CRIMINAL ACTION FOR UNSWORN FALSIFICATION TO
AUTHORITIES, UNDER SECTION NO 4904 OF THE CRIMINAL CODE OF THE COMMONWEALTH OF PENNSYLVANIA, WITH THE
CONSEQUENCE OF A PENALTY OF ONE (1) YEAR IN JAIL, AND/OR A $2,500 FINE.
I HEREBY CERTIFY THAT ALL THE ABOVE INFORMATION IS ABSOLUTELY TRUE & CORRECT TO
THE BEST OF MY KNOWLEDGE.
VICTIM'S SIGNATURE:_________________________________________________________________
I
I
M
M
P
P
A
A
C
C
T
T
S
S
T
T
A
A
T
T
E
E
M
M
E
E
N
N
T
T
A copy of this form will be given to the Judge before the Defendant is sentenced. It is important for the
courts to know how this crime has affected your life. If there is anything additional you would like the Judge
to know please write those thoughts on the back of this page or feel free to write him/her a letter instead.
FEEL FREE TO ADD ADDITIONAL PAGES IF NEEDED.
Directions: Please CIRCLE the word that best describes the impact of the crime.
1. As a result of this crime:
How much have you feared for your safety? None Mild Moderate Severe Extreme
How much anxiety have you experienced? None Mild Moderate Severe Extreme
How much sadness have you experienced? None Mild Moderate Severe Extreme
How much anger have you experienced? None Mild Moderate Severe Extreme
How much difficulty have you had trusting others? None Mild Moderate Severe Extreme
2. Since the crime occurred, how much difficulty have you had:
Difficulty concentrating on doing something for ten minutes?
None Mild Moderate Severe Extreme/Cannot Do
Difficulty remembering to do important things (i.e. paying bills, returning phone calls)?
None Mild Moderate Severe Extreme/Cannot Do
Difficulty taking care of household responsibilities?
None Mild Moderate Severe Extreme/Cannot Do
Difficulty taking care of work responsibilities/school responsibilities?
None Mild Moderate Severe Extreme/Cannot Do
Difficulty maintaining friendships?
None Mild Moderate Severe Extreme/Cannot Do
3. How much of an impact has this crime had on your life?
None Mild Moderate Severe Extreme
4. How much of an impact has this crime had on your children/family/friends?
None Mild Moderate Severe Extreme
DEFENDANT: ____________________________________________ Docket #: _____________________
VICTIM IMPACT STATEMENT
BE ADVISED: This will be read by the Judge, District Attorney, Defendant, and the Defendant’s Attorney.
**** PLEASE FEEL FREE TO ADD ADDITIONAL PAGES IF NEEDED.
1. How did this crime affect you (and your family)?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2. What was the financial impact on you?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
3. What would you want to happen now?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Signature: ___________________________________________________ Date: _____________________
DEFENDANT: ____________________________________________ Docket #: _____________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

N E O M U Q S R (County of Erie)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document