'm Imnact Statement

lfyou need more space to answei any or the following questions, please feel tree to use as much
paper as you need, and simply attoeli these sheets ofpapet to this impact Thank 

- State of Oklahoma vs.



  
    

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JAN 6 2014

  

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ssistant Disfiict Ammey:

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- Name of Victim:
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If Vlctim is aMinor, Name of Parent/Guatdian:
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- Relationship of Victim to Offender:
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- As a result of this crime. were you or your [amin member physically or emotionally
injured? If yes. complete as many as apply:

- lneuned the following physical injuries:
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- Was hospitalized for days.

- Incurred medical or counseling expenses 
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- Anticipate additional penses of 

For:

- You may want to write about how long the injuries lasted or how long they are expected to

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- Has this crime affected your ability to perform your work, make a living, run a household,
go to school or enjoy any other activities you previously performed ni enjoyed? lrso, please

explain how these activities have been afiectcd by this crime.
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watka 077 5m <How has this crime affected your lifestyle or your family?s lifestyle? Please feel free to
discuss your feelings about what happened and how it has affected your general well being.

Has this crime affected your relationship with any family members, friends, co-workers and
other people?

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Thank you for the thoughts and information you have provided.

Signature Win/7? Date 

Please return Victim Impact Statement to: Gayellen Johnson - Victim Witness Center
Tulsa County District Attorneys Office
500 S. Denver, Suite #860
Tulsa, OK 74103

Direct Line: 918-596-4918
Fax: 918?596-4923
gjohnson@tulsaeounty.org