1450 Energy Park Drive, Suite 200 | St. Paul, MN 55108
Main: 651.361.7250 | Fax: 651.642.0223 | TTY: 800.657.3830
Email: victimassistance.doc@state.mn.us | https://mnhaven.mn.gov
Contributing to a safer Minnesota
EQUAL OPPORTUNITY EMPLOYER
VICTIM NOTIFICATION REQUEST FORM
Individuals must submit a request containing current contact information in order to receive information from the
Minnesota Department of Corrections pursuant to Minn. Stat. §611A.06. Requests may be submitted by mail, fax, or
email. The Minnesota Department of Corrections will acknowledge receipt of your request within 10 business days.
Victim Assistance Program staff may contact you to follow up to your request, if needed.
Date: _______________________
Contact Information
First Name: ___________________________________ Last Name: ___________________________________
Street Address: ______________________________________________________________________________
City: ____________________________ State: _____________ Zip Code: ______________________________
Email Address: __________________________________________________
Phone Number: _____________________________________ Phone Type: ☐ Home ☐ Cell ☐ Work ☐ other
Is it okay to leave a voicemail? ☐ Yes ☐ No
Notification Options
Account Type: (please select those that you feel best describe your association to the offender. Please select at least
one.)
☐ Victim ☐ Victim Family Member ☐ Offender Family Member
☐ Community Member ☐ Victim Advocate ☐ Criminal Justice Professional
☐ Law Enforcement ☐ other ______________________________
Select how you want to receive notification:
☐ Email ☐ U.S. Postal Mail (letter) ☐ both (Email and U.S. Postal Mail)
Preferred language:
☐ English ☐ Spanish ☐ Hmong ☐ Somali ☐ other ______________________
Notifications you would like to receive:
☐ Incarceration Custody Changes ☐ Release Notifications
☐ Early Release Programs ☐ Supervision Custody Changes
☐ Offender Escape or Apprehension
Offender Information Provide as much information as is known.
First Name: _________________________________ Last Name: _________________________ OID: _______________
Date of Birth: ________________________________________
Submit this form to DOC Victim Assistance Program 1450 Energy Park Drive Suite 200, St. Paul, MN 55108
Fax: 651.642.0223 or Email: VictimAssistance.doc@state.mn.us
For additional information visit https://mn.gov/doc/victims/
