Form VS-01 "Victim Notification Request Form" - North Carolina

What Is Form VS-01?

This is a legal form that was released by the North Carolina Department of Public Safety - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 7, 2018;
  • The latest edition provided by the North Carolina Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form VS-01 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Public Safety.

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Download Form VS-01 "Victim Notification Request Form" - North Carolina

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NC Department of Public Safety’s Victim Services
Victim Notification Request Form
PERSON / ORGANIZATION REQUESTING NOTIFICATION ABOUT AN OFFENDER
First: ______________________________ Middle Initial: _______ Last: ___________________________ Suffix: _________
Business/Organization: ________________________________________________________________________________
Mailing Address: _________________________________________________ Home Phone (_______) _______________
City: __________________________ State: _____ Zip Code: _____________ Work Phone (_______) _______________
County: ______________ Email: ____________________________________ Cell Phone
(_______) _______________
PROVIDE A 4 DIGIT PIN* OF YOUR CHOICE
SELECT HOW YOU WOULD LIKE TO BE NOTIFIED
&
Choose your notification method below. Please note that if you are registering to receive notifications about state
prisoners and probationers, you will receive notifications by mail and by the methods you choose below.
WRITE your PIN here: ___ - ___ - ___ - ___
(Create a PIN that is four numbers and that you will remember.)
 Phone indicate:  home and/or
 cell (Do not register a work number without the employer’s permission. The NC
SAVAN system will continue to call until the PIN is entered.)
 Text (mobile/cell phones only)
 Email
*PIN = personal identification number that you choose to verify your registration
YOUR RELATIONSHIP TO THE VICTIM
Please check the appropriate box to indicate how you are related to the victim in this case.
I am:
 a direct victim of this crime  a family member of the victim
 an indirect victim of the crime
 an interested party
VICTIM INFORMATION
 Please check if the victim of this crime is under the age of 18.
 Please check if the victim of this crime is deceased.
First: ______________________________ Middle Initial: _______ Last: ___________________________ Suffix: __________
Business/Organization: ________________________________________________________________________________
OFFENDER INFORMATION
Offender is:  in a county jail  in a state prison  on parole
 on probation/post-release supervision  unknown
First: ______________________________ Middle Initial: _______ Last: ___________________________ Suffix: __________
Offender’s County Jail # or NCDPS #: _______________________ County of Conviction: ___________________________
Crime(s): __________________________________________________________________________________________
Court Case #(s): ____________________________________________________________________________________
SEND THIS FORM TO
By Fax: 919-715-1256 By Email: SVC_DPS_VictimServices@ncdps.gov By Mail: NC Dept. of Public Safety
Victim Services
4223 Mail Service Center
Raleigh, NC 27699-4200
For victim services questions: Victim Services 1-866-719-0108, Monday-Friday, 8am-5pm
For operator assistance with phone, email, text or TTY notifications: 1-877-627-2826, 24 hours/day
For web information:
www.ncdps.gov
VS-01 – Revised 12-7-18
NC Department of Public Safety’s Victim Services
Victim Notification Request Form
PERSON / ORGANIZATION REQUESTING NOTIFICATION ABOUT AN OFFENDER
First: ______________________________ Middle Initial: _______ Last: ___________________________ Suffix: _________
Business/Organization: ________________________________________________________________________________
Mailing Address: _________________________________________________ Home Phone (_______) _______________
City: __________________________ State: _____ Zip Code: _____________ Work Phone (_______) _______________
County: ______________ Email: ____________________________________ Cell Phone
(_______) _______________
PROVIDE A 4 DIGIT PIN* OF YOUR CHOICE
SELECT HOW YOU WOULD LIKE TO BE NOTIFIED
&
Choose your notification method below. Please note that if you are registering to receive notifications about state
prisoners and probationers, you will receive notifications by mail and by the methods you choose below.
WRITE your PIN here: ___ - ___ - ___ - ___
(Create a PIN that is four numbers and that you will remember.)
 Phone indicate:  home and/or
 cell (Do not register a work number without the employer’s permission. The NC
SAVAN system will continue to call until the PIN is entered.)
 Text (mobile/cell phones only)
 Email
*PIN = personal identification number that you choose to verify your registration
YOUR RELATIONSHIP TO THE VICTIM
Please check the appropriate box to indicate how you are related to the victim in this case.
I am:
 a direct victim of this crime  a family member of the victim
 an indirect victim of the crime
 an interested party
VICTIM INFORMATION
 Please check if the victim of this crime is under the age of 18.
 Please check if the victim of this crime is deceased.
First: ______________________________ Middle Initial: _______ Last: ___________________________ Suffix: __________
Business/Organization: ________________________________________________________________________________
OFFENDER INFORMATION
Offender is:  in a county jail  in a state prison  on parole
 on probation/post-release supervision  unknown
First: ______________________________ Middle Initial: _______ Last: ___________________________ Suffix: __________
Offender’s County Jail # or NCDPS #: _______________________ County of Conviction: ___________________________
Crime(s): __________________________________________________________________________________________
Court Case #(s): ____________________________________________________________________________________
SEND THIS FORM TO
By Fax: 919-715-1256 By Email: SVC_DPS_VictimServices@ncdps.gov By Mail: NC Dept. of Public Safety
Victim Services
4223 Mail Service Center
Raleigh, NC 27699-4200
For victim services questions: Victim Services 1-866-719-0108, Monday-Friday, 8am-5pm
For operator assistance with phone, email, text or TTY notifications: 1-877-627-2826, 24 hours/day
For web information:
www.ncdps.gov
VS-01 – Revised 12-7-18