Lost Wages/earnings Claim Form printable pdf download

Lost Wages/earnings Claim Form

LOST WAGE CLAIMS

Who may be eligible for Lost Wage Claim Reimbursements:

1. An innocent victim of violent crime who either physically or mentally is unable to

immediately return to work due to the crime. The victim must have had gainful

employment immediately prior to the crime, have an offer of employment, or be a

seasonal employee.

2. A parent/guardian who must miss work to take a dependent to a medical or mental health

provider due to the dependent being an innocent victim of a violent crime or whose

dependent was critically injured due to being an innocent victim of a violent crime and

must be cared for by the parent/guardian.

The following must be included in order to receive lost wage reimbursement:

1. Employment Verification Form (filled out by employer, unless the victim is self-

employed)

2. Lost Wages/Earnings Claim Form (filled out by victim/claimant)

3. Claim Form For Disability Verification

a. Must be submitted when more than one week of work is missed

b. Must be completed and signed by the victim's doctor

c. Disability Dates MUST be filled in

4. Proof of income

a. Two or three payroll check stubs for the periods immediate prior to the crime

b. If payroll check stubs are not possible, or if the victim was self-employed, submit a

copy of the previous year's federal income tax return

5. If lost wages reimbursement is being claimed to take a child to a medical or mental health

provider, paperwork documenting the visit(s) must be attached along with the

information above.

Lost Wages/earnings Claim Form