Form : Mo 812-1321 - Application For Crime Victims' Compensation
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4FOR OFFICE USE ONLY
MISSOURI DEPARTMENT OF PUBLIC SAFETY
Claim No.
APPLICATION FOR CRIME VICTIMS’ COMPENSATION
INSTRUCTIONS:
1. Type or Print clearly in ink.
2. Last page of this form must be signed by claimant and notarized.
3. If victim is a minor or an incompetent person, application MUST be made by a parent or guardian.
4. If a question is NOT APPLICABLE, answer with N/A.
MAILING ADDRESS
TELEPHONE NUMBER
RELAY MISSOURI
CRIME VICTIMS’ COMPENSATION PROGRAM
573-526-6006
1-800-735-2966 (TDD)
P.O. BOX 1589, JEFFERSON CITY, MISSOURI 65102-1589
1-800-347-6881
1-800-735-2466 (VOICE)
How did you find out about the Crime Victims’ Compensation Program?
Police (Agency Code ____________)
Victim Assistance (Agency Code ____________)
Prosecutor (Agency Code ____________)
Hospital
Funeral Home
Friend/Family
SECTION I PRIMARY VICTIM INFORMATION
Name of Victim (Last, First and Middle)
Social Security Number
Current Street Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Country of Birth - National Origin*
Is Victim Deceased?
Yes
No
Birthdate
Age
Sex
Marital Status
Married
Divorced
Male
Female
Single
Separated
Widowed
Race Ethnic (Check One)*
Handicapped Prior to Crime*
Yes
No (Explain)
1. White
2. African American
7. Other: _____________
3. Hispanic
4. American Indian/Alaskan Native
Date Crime Occurred
5. Asian Pacific Islander
6. Race Ethnic (optional)
Has the victim been convicted of two felonies within the past ten (10) years?
Yes
No
Explain : ____________________________________
SECTION II
CLAIMANT INFORMATION
Complete this section if someone other than the victim is filing claim (i.e. parent/legal guardian).
Name of Claimant (Last, First and Middle)
Social Security Number
Street Address
City
State
Zip Code
Relationship to Victim
Was victim living with you at the time
Home Telephone Number
Work Telephone Number
of the crime?
Yes
No
Birthdate
Age
Sex
Marital Status
Married
Divorced
Male
Female
Single
Separated
Widowed
SECTION III OTHER COMPENSABLE VICTIM *CHAPTER 595 (If more than one, use additional sheet.)
Name of other compensable victim (Last, First and Middle)
Social Security Number
Current Street Address
City
State
Zip Code
Home/Work Telephone Number
Relationship to Primary Victim
Country of Birth - National Origin* Handicapped Prior to Crime*
Yes
No
Birthdate
Age
Sex
Marital Status
Married
Divorced
Male
Female
Single
Separated
Widowed
Race Ethnic (Check One)*
1. White
3. Hispanic
5. Asian Pacific Islander
7. Other: _________________________
2. African American
4. American Indian/Alaskan Native
6. Race Ethnic (optional)
Was the other compensable victim living with the primary victim at the time of the crime? (Chapter 595)
Yes
No
If yes, explain: _________
__________________________________________________________________________________________________________________________
Has the other compensable victim been convicted of two felonies within the past ten (10) years?
Yes
No
If yes, explain: _______________
__________________________________________________________________________________________________________________________
* This information is requested solely for compliance with Federal Civil Rights under Section 1407(c) of the Victims of Crimes Act of
1984. It will be used only for statistical purposes.
NOTE
APPLICATION MUST BE SIGNED AND NOTARIZED ON BACK PAGE. PHOTOCOPIES ARE NOT ACCEPTABLE.
MO 812-1321 (2-14)
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