Pccd Victims Compensation Assistance Program Short Form (Page 2 of 4) in pdf

Pccd Victims Compensation Assistance Program Short Form Page 2

PCCD Victims Compensation Assistance Program Short Form

Your cooperation with the Program and the submission of complete and accurate information will assist us

in processing your claim in a timely manner.

IMPORTANT NOTE: You do not have to wait until the trial is over or all of your bills are received

in order to file a claim. You may file a claim if there is no known offender or if an arrest has not been made.

General instructions for submitting your claim:

Please print clearly.

Complete only those sections that apply to your claim.

Provide an accurate address and a safe phone number where you can be reached during

the day.

Provide as many of the requested documents as you can when filing your claim. You may

submit your claim even if you do not have all the required documents. The Program may

request additional information once the claim is received.

Sign the Acknowledgement and Reimbursement Agreements and the Authorization

to Obtain Information sections on the back of the claim form.

If you would like assistance in filing your claim you may contact the Victim Service Program

listed on the back of this form. If no agency is listed, you may contact the Victims

Compensation Assistance Program at 800-233-2339 for assistance.

Please Note: It is important that you inform the Program if you change your address or

phone number. In order to process your claim, we must be able to contact you.

The Victims Compensation Assistance Program is the payor of last resort. This means your award will be

reduced by the monies you receive from any other source as a result of the crime, such as insurance,

restitution, and civil suit settlements including monies received for pain and suffering.

We will make every effort to process your claim as quickly and efficiently as possible.

Date Claim mailed____________________________ (keep this page for your information.)

800-233-2339

Help for Victims of Crime in Pennsylvania

800-233-2339

Pccd Victims Compensation Assistance Program Short Form Page 2