Victims’ Rights Request Form – Clermont County Prosecutor

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Form Completed By

Reporting Agency

Agency Telephone No.

Reporting Officer / Badge No.

Report No.

Case No. (if known)

Defendant / Suspect (if known)

Court

Arraignment / Bond Hearing

Date

Time

Victim of a violent offense, sexually orientated offense, or violation of protection order

Yes

Victim Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Preferred Method of Contact

Telephone

Text Message

U.S. Mail

Please provide my name and contact information, and that of my representative, if applicable, to the custodial agency, if any.

Yes

I would like to request the following rights:

I WANT my name, address, and identifying information removed from:

Law Enforcement records

Prosecutor records

Court records

I WANT notice of the arrest, escape, or release of the offender - Referral to VINE (Victim Information Notification Everyday)

Yes

I WANT to confer with the prosecutor in the case in addition to the times listed above

Yes

I WANT reasonable and timely notice of all public proceedings

Yes

I WANT to appoint a victim's representative

Yes

Representative's Name - if requested

First Last

Phone

I would like to request an interpreter:

Foreign language interpreter

American Sign Language interpreter