Travel/appointment Verification Information Form printable pdf download

TRAVEL/APPOINTMENT

VERIFICATION INFORMATION FORM

This form should be completed when the victim/claimant is requesting reimbursement for travel

expenses or lost wages incurred to attend crime related medical/counseling appointments, police

investigation appointments, criminal proceedings, post-conviction or post-adjudication proceedings

(executions) or a victim’s funeral.

TRAVEL EXPENSES:

Traveling distance must be more than 20 miles one way. If travel exceeds 60 miles one way,

lodging and food reimbursement may be claimed. Per-diem for food is reimbursed at the state per

diem rate which is computed over a 24-hour clock and requires an overnight stay. Receipts are not

required for per-diem reimbursement. Receipts are required for lodging.

Please provide a complete start address and destination address. This includes the street number

and name, city, state and zip code. P.O. Boxes are not acceptable. The destination address must

include the name of the facility.

The medical provider/counselor, criminal justice official, funeral service officiant/director or victim

assistance coordinator must indicate the purpose of the appointment/travel (see form).

The medical provider/counselor, criminal justice official, funeral service officiant/director or victim

assistance coordinator must sign and print the form to verify your appointment/travel and

provide a telephone number. If signatures are not available we will need copies of bills verifying

the date of the appointment or a letter from the provider of service verifying the appointment/travel

dates. The criminal justice official/victim assistance coordinator may also submit a letter verifying

your appointment/travel.

LOST WAGES:

The medical provider/counselor, criminal justice official, funeral service officiant/director or victim

assistance coordinator must sign and print the form to verify your attendance at the

appointment/funeral and provide a telephone number. If signatures are not available we will need

copies of bills verifying the date of the appointment/funeral or a letter from the provider of service

verifying the appointment dates. The criminal justice official/victim assistance coordinator may also

submit a letter verifying your appointment.

The medical provider/counselor, criminal justice official, or victim assistance coordinator must

indicate the purpose of the appointment (see form).

The victim or claimant’s employer will be contacted to verify employment, income, and days

missed from work. Please provide the employer’s name, address, phone number, and the name of

the contact person on Travel/Appointment Verification Form. If you are self-employed, we will

require your most recent tax return. Contact IRS @ 1-800- 908-9946 to obtain a computer printout.

If any of this information is not included on the form, the form will be returned to you to complete.

If you have any questions regarding these benefits or this form, please contact our office at 1-800-983-9933 or (512)-

936-1200.

NOTE: A victim or claimant who is subpoenaed as a “non-resident witness” whose expenses are reimbursable

under the Texas Code of Criminal Procedure Article 35.27 shall not be eligible for travel, lodging and meal

reimbursement under our program. These expenses are eligible for reimbursement through the District

Attorney’s office.

Reviewed 8/25/11

Travel/appointment Verification Information Form