By completing this document, I certify that I personally have watched the videos, read the stories in the booklet, and answered the questions to the best of my ability OR, out of necessity, had the questions read to me and/or written out for me with the assistance of a third party.
I affirm this day of , that the foregoing statement is true, and I understand that this document may be filed in an action or proceeding in a court of law, and that a false statement would be considered felony perjury, punishable by a Fine and/or imprisonment. If you print your name below and submit this document electronically you are swearing that you are the person who completed the electronically submitted documents.
Third Party Assistance is if you needed the assistance of another person to complete any of the part of the Victim Impact Panel Program. If Third Party Assistance was used this section must be completed.
No, thanks. I'm not interested.
