Travel/appointment Verification Information Form (Page 2 of 2) in pdf

STATE OF TEXAS

OFFICE OF THE ATTORNEY GENERAL

CRIME VICTIM SERVICES DIVISION

TRAVEL / APPOINTMENT VERIFICATION FORM

This information is required to calculate mileage and verify the appointment you attended.

1) Victim/Claimant:

Social Security Number:

Patient’s Name (attendee at appointment):

Claim Number:

Were you subpoenaed for trial on any of the listed dates?

yes ____ no ____

** The last 2 columns on the right MUST be completed/verified by the appropriate

If so, provide a copy of your subpoena.

individual listed in the last column.

2) WHAT ARE YOU

Indicate the complete

**Indicate the type of appointment

** SIGNATURE & printed name*,

DATE(S)

CLAIMING?

appointment

START ADDRESS

DESTINATION ADDRESS

phone number of Provider/

(number of

(physical address/ city/ state/

(diagnosis code, criminal case/cause # and

Counselor, Law enforcement/

hours there)

zip code of residence)

(name and physical address/

purpose of appointment, execution, funeral)

Criminal Justice Official, Victim

(Check all that apply)

TRAVEL MUST BE OVER 20

city/ state/ zip code of facility)

Assistance Coordinator that is

bereavement

MILES ONE WAY FROM THE

verifying the appointment or a copy

STARTING ADDRESS.

of bills to verify appointments.

Travel

Lost wages

Lost Wages for

bereavement

Travel

Lost wages

Travel

Lost wages

Travel

Lost Wages

3. If travel is over 60 miles you may be eligible for lodging and food reimbursement at state rates. Receipts are required for lodging. Food is paid at the current state per-diem rate and receipts

are not required. If commercial travel (airplane, bus, train, taxi) was used, submit a copy of your receipt.

4. If you are claiming lost wages for the attendance of crime related doctor’s/counseling appointments, funeral or criminal justice proceedings, we will contact your employer to verify your

income and the dates/hours you were unable to work. If self employed, we will require your most recent tax return. Contact IRS @ 1-800-908-9946 to obtain a computer printout.

PLEASE PROVIDE THE FOLLOWING INFORMATION CONCERNING YOUR EMPLOYER

Employer name:

Employer Phone #:

Employer address/

Employer Fax #

city/state/zip code:

5) Victim / Claimant Signature:

Date:

Revised 8/25/11