Forensic Interview Form (Page 3 of 3) in pdf

SECTION 6

In this section, please indicate which one applies.

CRIME VICTIMS COMPENSATION PROGRAM

 Our Agency helped the victim with completing and/or submitting the required Victims Compensation application and documents.

 Our Agency only told the victim about the Victims Compensation Program or shared materials about the Program with the victim.

The victim may apply for benefits offered through the Crime Victims Compensation Program for other expenses incurred as a result of the victimization

to include the following:

Medical Expenses: up to $15,000

Counseling Expenses: up to $3,000

Crime Scene Sanitization Expenses: up to $1,500

Funeral Expenses: up to $6,000

Economic Support Expenses: up to $10,000

SECTION 7.

This section must be read and signed by the person who conducted the Forensic Interview.

INTERVIEWER ACKNOWLEDGEMENT

With my signature, I declare and affirm under penalty of perjury, pursuant to O.C.G.A. § 17-15-11, that the information provided above in Sections 1

and 4; as well as the statements listed below on this Application for Payment are true and correct:

I have specialized training to conduct forensic interviews appropriate to the developmental age and abilities of children, or the developmental,

cognitive, and physical or communication disabilities presented by adults. (Please attach a copy of license or training certificate)

The interview was conducted as a part of an investigation of an alleged crime and in the context of a multidisciplinary and diagnostic team, or

in a specialized setting such as a child advocacy center.

Name of Forensic Interviewer (Printed) _____________________________________________________________________________

__________________________________________________________________________ Date: (MM/DD/YY) _______/_______/_________

Forensic Interviewer’s Signature

SECTION 8.

This section must be read and signed by the Executive Director or their designee.

AGENCY ACKNOWLEDGEMENT

With my signature, I declare and affirm under the penalty of perjury, pursuant to O.C.G.A. § 17-15-11, that the information provided above in

Sections 1-7; as well as the statements listed below on this Application for Payment are true and correct:

I confirm that the victim listed in Section 1 of this application is not identified as the offender/suspect in this incident or alleged incident for which

the forensic interview was conducted.

I confirm that the victim/witness listed in Section 1 of this application was physically present during the commission of the incident/alleged

incident for which the forensic interview was conducted.

I confirm the interview is not a 2

follow-up interview for which we have already billed the Crime Victims Compensation Program.

Name of Executive Director or Designee (Printed) _______________________________________________________________________

__________________________________________________________________________ Date: (MM/DD/YY) _______/_______/_________

Signature of Executive Director or Designee

Send the completed Application for Payment and required documentation to the Criminal Justice Coordinating Council, Forensic Interview Program -

104 Marietta Street NW, - Suite 440 - Atlanta GA 30303. If you have questions, please call (404) 657-2222 or (800) 547-0060. You can also visit our

website at crimevictimscomp.ga.gov for more information.

Page 2 of 2

Revised 1.30.17

Forensic Interview Form Page 3

Related Articles

Related forms

Related Categories