This form includes:

• sections to help you describe the effect of the crime on you and your views about the Supervision Order being made by the court• a Statutory Declaration, which makes the Victim or Family Member Report a legal document.

Victim or Family Member Report FORM

How to complete this form

There are two ways you can fill in this interactive form:

1. Either save a copy of the form to your computer, open the saved copy and fill it in on screen, then print it out and complete the Statutory Declaration on page 9.

2. Or you can print a copy of the blank form and fill it in by hand.

NOTE: For either method the Statutory Declaration on page 9 must be completed, signed and witnessed before forwarding the form to the Office of Public Prosecutions.

Send your signed, completed form to:

Office of Public Prosecutions, PO Box 13085, Melbourne VIC 8010

1

SecTion 1 Personal information (this section is compulsory)

Your name: _____________________________________________________________________

Name of Supervised Person: ______________________________________________________

I am completing this report as a (click one/tick one):

Victim of crime

Family member of a Supervised Person

Victim of crime and family member of a Supervised Person

2

SecTion 2 The effect of the Supervised Person’s conduct

Use this section to describe the effect of the Supervised Person’s conduct on you.

You may consider referring to:

their past or current conduct towards you

their past or current conduct towards other people (for example, members of the public, family members).

Please attach additional pages if required.

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SecTion 3 Your views regarding the Supervision order

In considering whether to make, change or cancel a Supervision Order, the court will consider:

whether the Supervised Person is likely to endanger themselves or other people because of their mental impairment

the need to protect people from any danger

whether there are adequate resources available for the treatment and support of the person in the community.

Use this section to describe:

how you feel about the current conditions of the Supervision Order

how you feel about any possible changes to the Supervision Order (for example, if extended leave was granted)

your views about any danger you think there may be to the Supervised Person, yourself, or someone else if the Supervision Order was changed

the resources you think are/are not available for the treatment and support of the Supervised Person in the community.

Please attach additional pages if required.

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SecTion 3 continued…. _____________________________________________________________________________________________________________

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SecTion 4Further information

Use this section to provide the court with any further information you think may assist the court to determine:

any conditions it may impose on a Supervision Order

whether or not to grant a person extended leave.

Please attach additional pages if required.

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SecTion 4 continued….

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9

noTe: In order to complete the Victim and Family Member Report you must complete this statutory declaration (section 5), regardless of whether you choose to fill out the form on screen or by hand. The form should be printed and the statutory declaration (this page) should be signed and witnessed before sending to the Office of Public Prosecutions.

SecTion 5Statutory Declaration (this section is compulsory)

I do solemnly and sincerely declare that this declaration is true and correct, and I make it with the understanding and belief that a person who makes a false declaration is liable to the penalties of perjury.

Declared at _________________________________________________________________ in the State of Victoria,

on this _____________ day of ____________________________ 20 _______

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Signature of person making this declaration

[to be signed in front of an authorised witness*]

Before me,

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Signature of Authorised Witness

*[The authorised witness (for example: justice of the peace, pharmacist, police officer, lawyer, court registrar, bank manager, medical practitioner, dentist) must print or stamp his or her name, address and title under section 107A of the Evidence (Miscellaneous Provisions) Act 1958 (as of 1 January 2010), (previously Evidence Act 1958).]

Send your signed, completed form to:

Office of Public Prosecutions PO Box 13085 Melbourne VIC 8010

Published by the Office of Public Prosecutions for the State of Victoria. First published November 2012. © Office of Public Prosecutions 2012

Department ofJustice