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2. FORM COMPLETED BY:*
   -- Select One --Law EnforcementProsecutorVictim
3. DATE & TIME COMPLETED*
   DATE & TIME COMPLETED

   DATE & TIME COMPLETED
5. REPORTING AGENCY

   Union Township Police Department

6. REPORT NO.
8. REPORTING OFFICER
9. BADGE NO.
11. AGENCY PHONE NO.

    (513)752-1230

12. CASE NO.
14. COURT
    -- Select One --Municipal Court - Clermont CountyCommon Pleas Court - Clermont CountyJuvenile - Clermont County
15. ARRAIGNMENT - DATE & TIME (IF KNOWN)
    ARRAIGNMENT - DATE & TIME (IF KNOWN)

    ARRAIGNMENT - DATE & TIME (IF KNOWN)
17. AUTOMATIC RIGHTS—YOU DO NOT NEED TO REQUEST THESE RIGHTS

    - The right to be informed of your rights. 

    - The right to be treated with fairness and respect for your safety, dignity, and privacy.

    - The right to reasonable protection from the accused or any person acting on behalf of the accused. 

    - The right to information about the status of the case. 

    - The right to refuse a defense interview, deposition, or other discovery request. 

    - The right to object to defense requests for access to your confidential information, including medical, counseling, school or employment records, access to your personal devices or on-line accounts, or other personal information. 

    - The right to be present at all public proceedings. 

    - The right to have a support person with you during proceedings. 

    - The right to confer with the prosecutor at certain points in the case, including before pretrial diversion is granted, before the prosecutor amends or dismisses an indictment, information, or complaint, before the prosecutor agrees to a negotiated plea, and before a trial or adjudicatory hearing. 

    - The right to tell the court your opinion in public proceedings involving release, plea, sentencing, disposition, parole, and any other hearing that involves victims’ rights. 

    - The right to object to unreasonable delays. 

    - The right to full and timely restitution from the offender.

19. I WANT my name, address, and identifying information to be redacted (removed) from: (Check all that apply)

    1. Law Enforcement Records
    2. Prosecutor Records
    3. Court Records
21. I WANT notice of the arrest, escape, or release of the offender.

    1. Yes
    2. No
23. I WANT reasonable and timely notice of all public proceedings.

    1. Yes
    2. No
25. I WANT to confer with the prosecutor in the case in addition to the times listed above.

    1. Yes
    2. No

    _{-If this matter involves cross complaints, the Clermont County Prosecuting Attorney’s office will communicate with you through your defense counsel, or with you directly with counsel present}

27. I WANT to be notified of subpoenas, motions, or other requests to access any of my personal information.

    1. Yes
    2. No
29. I WANT interpretation services during contacts with criminal justice system officials.

    1. Foreign language interpreter
    2. American Sign Language interpreter
30. If foreign language interpreter is needed:
32. Victim of a violent offense, sexually oriented offense, or violation of a protection order.*

    1. Yes
    2. No
34. *As a victim, it is your responsibility to keep law enforcement agencies, prosecutors, courts, and custodial agencies up to date with your current contact information.
36. VICTIM'S INFORMATION*
37. DOB*
39. ADDRESS*
41. CITY*
42. STATE*
43. ZIP CODE*
45. PHONE NUMBER*
46. EMAIL ADDRESS
48. PREFERRED METHOD OF CONTACT (CHECK ALL THAT APPLY):*

    1. Telephone
    2. Text Message

    1. Email
    2. U.S. Mail
50. I WANT to appoint a victim's representative.

    1. Yes
    2. No
52. VICTIM'S REPRESENTATIVE (IF REQUESTED BY VICTIM):
53. DOB
55. ADDRESS
57. CITY
58. STATE
59. ZIP CODE
61. PHONE NUMBER
62. EMAIL ADDRESS
64. BUSINESS VICTIM USE ONLY

    As a representative of my business, I hereby OPT OUT of the business's victims' rights in this case and future cases unless I notify law enforcement, the prosecutor, or the court otherwise.

    1. Agree
66. BUSINESS NAME & NAME OF REPRESENTATIVE
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field