Pccd Victims Compensation Assistance Program Short Form Page 3
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4PCCD Victims Compensation Assistance Program Short Form
Claim #_______________
(For Official Use Only)
Please complete this entire section of the form. In order to process your claim, we must be able to contact you.
Victim Information
l Male l Female
Name__________________________________________Date of Birth______/_____/_____ SS#________________________
Address_______________________________________City_____________________State __________Zip Code __________
County_______________________Safe Daytime Phone____________________Other Safe Phone_____________________
If victim is the claimant, write "SAME." If someone other than victim is filing, complete the entire section.
Claimant Information
Name__________________________________________Date of Birth______/_____/_____ SS#________________________
Address_______________________________________City_____________________State __________Zip Code __________
County_______________________Safe Daytime Phone____________________Other Safe Phone_____________________
l Male l Female
Relationship to Victim____________________________
Crime Information
Date of Crime______/______/______ Date Reported to Police_____/______/______ or Date PFA filed______/_____/_____
Was this a crime of domestic violence? ___yes _____no
Did the crime involve a motor vehicle? ___yes _____no
Did the crime occur at work? ___yes _____no
Location of crime (street name and number)_________________________________________________________________
City______________________________________State ____________ County ______________________________________
Police Department___________________________________Police Incident #______________________________________
Person(s) who committed the crime_________________________________________________________________________
Briefly describe crime and injuries: _________________________________________________________________________
_________________________________________________________________________________________________________
Please complete the section(s) for the benefit(s) you are applying for and provide as much of the requested information that you can
at this time. The Program may request additional information once the claim is received.
Benefit: Medical/Counseling Expenses
Benefit: Funeral Expenses/Loss of Support
Did you incur medical expenses?___yes _____no
Did you incur funeral expenses?___yes _____no
Did you incur counseling expenses?___yes _____no
Did you receive any monies due to the death? (Veteran’s
benefits, life insurance, Social Security)___yes _____no
Provide
itemized medical or counseling bills.
Were you or others financially dependent on the
Do you have insurance to cover your
deceased victim? ___yes _____no
medical/counseling expenses? ___yes _____no
Provide
copies of the itemized funeral bills/receipts,
If yes,
provide
insurance benefit statements showing
original death certificate, and statements of any benefits
payment or rejection of payment for these bills.
received.
Benefit: Stolen Cash
Benefit: Loss of Earnings
Did you have money stolen from you?___yes _____no
Did you miss work and lose pay?___yes _____no
Amount of money stolen $__________________________
Dates you missed work___/____/___ to ___/___/___
One of the following benefits must be your main source of
Employer’s name, address, and phone number:
income in order to file for stolen cash. Check all that apply.
________________________________________________
____ Social Security Benefit ____ Retirement/Pension(s)
________________________________________________
____ Disability ____ Court Ordered Child/Spousal Support
________________________________________________
Provide
a copy of your monthly benefit statement for the
Doctor’s name, address, and phone number who can
month and year of the crime.
verify you missed work because of the crime:
Do you have homeowner’s/renter’s insurance? __yes __no
________________________________________________
If yes,
provide
a copy of your insurance declaration page.
________________________________________________
Are you required to file IRS tax returns? ___yes ___no
________________________________________________
If yes,
provide
a copy of your most recent tax returns.
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