Form 23776 - Application For Benefits From Violent Crimes Compensation Fund
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1
2APPLICATION FOR BENEFITS
FROM VIOLENT CRIMES COMPENSATION FUND
State Form 23776 (R9 / 3-97)
* This state agency is requesting disclosure of Social Security numbers that are necessary to
accomplish the statutory purpose of this state agency according to IC 4-1-8.
** This information is for statistical purposes only and will not effect the eligibility of the claimant.
VICTIM INFORMATION
Name of victim (last, first, middle initial)
Marital status
*Social Security number
Sex
Date of birth
**Race
Male
White
Hispanic
American Indian
Black
Asian
Other
Female
Name of victim's dependents
CLAIMANT INFORMATION
Name of claimant (if different from the victim/last, first, middle initial)
* Social Security number
Address of victim or claimant (number and street)
Work telephone number
(
)
City, state, ZIP code
Home telephone number
(
)
Claimant's relationship to victim
INJURIES TO VICTIM
What injuries did the victim sustain as a result of the victimization?
Hospital for medical treatment
Address(number and street, city, state, ZIP code)
Name attending physician
Address (number and street, city, state, ZIP code)
CRIME AND PROSECUTION
Date of crime
Location of crime (city, state, county)
Briefly give a description of the crime
Date and time police report was filed
Name of law enforcement agency
Name of detective
Case number (if known)
AM
PM
Name of suspect (s)
Victim's relationship to suspect
Has suspect been arrested?
Yes
No
Were you willing to pursue prosecution?
Yes
No
If "No", please explain:
Cause number (if known)
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Parent category: Legal