Victim Notification Registration Form

• Section

Status

Victim

Witness

Victim Next of Kin

Guardian of Victim

Concerned Citizen

Pursuant to the Illinois Bill of Rights for Victims and Witnesses, please check the boxes for the services that you request be provided to you. While filing this survey with the Prisoner Review Board, please keep in mind that your responses and requests will be kept confidential.

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Response

Please notify me of any change in the custody status of the offender listed below (i.e. release, escape or death)

Please provide me with a current photograph of the offender listed below upon their release from custody

(Other) Please consider the additional conditions be placed on the offender listed below

No Contact with the following person(s) (Letter of Explanation Attached)

Other Conditions (Letter of Explanation Attached)

You may request special conditions be placed on an offender while the offender is on parole. Attach a letter describing the conditions you would like imposed along with the reason for your request. (For example: I don’t wish the offender to have contact with me while he is on parole because I testified against him/her, s/he threatened me, I was the victim and am scared, etc.) Also, please include a copy of any Order of Protections or any relevant report

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Name

Email

Address

City

State/Territory

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zipcode

Telephone (Home)

Telephone (Work)

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PLEASE NOTIFY THE PRB OF CHANGES IN ADDRESS OR TELEPHONE NUMBER

OFFENDER INFORMATION:

Offender's Name

Date of Birth

IDOC Number

County of Crime

Current Facility

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Attach any additional documents below.

File Attachment

Attach

Reset

Submit