Fillable Form : Mo 812-1321 - Application For Crime Victims' Compensation (Page 4 of 4) in pdf

ATTORNEY INFORMATION

It is not necessary to retain an attorney; however, if claimant wishes to be represented by an attorney in applying for benefits under Crime Victims’

Compensation, please complete the following. Attorneys are entitled to up to 15% of any award issued. The attorney will need to file an entry of appearance.

Attorney’s Name (Last, First, MI)

Telephone Number

Address

City

State

Zip Code

Signature of Attorney (if representing claimant in Crime Victims’ claim)

Date

AUTHORIZATION FOR RELEASE OF INFORMATION TO CONDUCT AN INVESTIGATION, TO

MAKE PAYMENTS DIRECTLY TO SUPPLIERS AND ASSIGNMENT OF SUBROGATION RIGHTS

I give permission to any attorney, hospital, funeral home, doctor, law enforcement agency, insurance company,

employer, welfare or social agency, or any federal, state or local government agency to release all records and

information that will help the Missouri Crime Victims’ Compensation Program to process my claim for compensation, to

allow copies of such records to be made and to answer any questions made by or on behalf of the Missouri Crime

Victims’ Compensation Program.

I understand that after receiving this form, the Missouri Crime Victims’ Compensation Program will investigate the truth

of the information provided as well as other matters regarding this claim; and I consent to such investigation. This

authorization is valid for three years from the date given below.

I acknowledge and agree that all or any part of any compensation awarded may be paid directly to any supplier of goods

or services on my behalf.

I further acknowledge and agree that the State of Missouri is subrogated, to the extent of any compensation awarded

to me, to all the claimant’s rights to recover benefits or advantages for economic loss from a source which is, or if readily

available to the victim or claimant would be, a collateral source, and I hereby assign such rights to the State of Missouri

so that it may protect its subrogation rights, and agree to assist the state in pursuing its subrogation rights.

I agree to notify the Department if I retain an attorney to represent me in a lawsuit related to this crime. I also agree to

notify the Department: 1) in the event I receive restitution payments from the offender, or 2) in the event I initiate any

legal proceeding or negotiations to recover damages related to the crime upon which this claim is based.

I certify that I have read and understand the statements above; and that the information I have given is true and correct

to the best of my knowledge and belief and that these benefits will be denied if any such statements are not true.

Signature of Claimant

Date

(If the victim is under 18 years of age, this application must be signed by the parent or legal guardian whose name appears in “Section II Claimant

Information”).

STATE OF MISSOURI

)

COUNTY OF ________________________ )

On this ______________ day of ___________________ 20 ____ , before me personally appeared ____________________ ,

(Name of Claimant)

to me known to be the person described in and who executed the foregoing Crime Victims’ Compensation Application and acknowledged

that __________________ executed the same as _______________ free act and deed. And said claimant declares that the information

(S/He)

(His/Her)

provided is true and correct to the best of ___________________ knowledge.

(His/Her)

Subscribed and sworn to before me at my office in ____________________________________________ the day and year first

(Notary’s Office Location)

above written.

_________________________________________________

(Notary Seal)

Notary Signature

My commission expires: ____________________________

MO 812-1321 (2-14)

Form : Mo 812-1321 - Application For Crime Victims' Compensation Page 4

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