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

PCCD Victims Compensation Assistance Program Short Form

Acknowledgement and Reimbursement Agreements

The Acknowledgement, Reimbursement and Authorization Agreements

must be signed before the claim verification process will begin.

In most cases two signatures are required. If the victim is age 14 or older, then he/she must also sign and then three signatures are required.

My signature below signifies I understand each of the following statements or points of law:

The decision to approve my claim is that of the Program's. I may object to all or part of the Program's decision in writing within 30 days from

the date of the decision. I must prove the exact amount of my losses before the Program will consider awarding compensation from the Crime

Victim's Compensation Fund. I may file for reimbursement for additional expenses incurred relating to the crime. My claim may be denied if I

do not cooperate fully with law enforcement agencies, the courts, and the Program or maintain a valid address with the Program. If I were to

make a false claim, it would be a criminal offense punishable as a misdemeanor under Section 11. 1303 of the Crime Victims Act. If I were to

make a false statement in this claim form with the intent to mislead the Program, it would be a criminal offense punishable as a misdemeanor

under 18 Pa. C.S. §4904.

understand that the Crime Victim's Compensation Fund is the payor of last resort. I specifically agree to inform the Program of and repay to

the Commonwealth any funds that I may receive from any other source that has not already been considered, as a result of the crime and to

the extent of the award. That is, I agree to repay any funds that I receive from the offender, any other person or source, which compensates

me for the injury I suffered, including any award for pain and suffering. I further agree that if the claim is at any time determined to be in error,

false or fraudulent, I will refund to the Program all sums of money paid by the Program.

________________________________________________________________________________________________________

Claimant's Signature

Date

Authorization to Obtain Information

This acknowledgement must be signed before the claim

verification process will begin.

I hereby authorize, in accordance with the privacy regulations under HIPAA (the Health Insurance Portability and Accountability

Act, 42 USC §§1320d et seq.) any hospital, physician, health care provider or other person who attended or examined (Name of

Victim)____________________; any funeral director or other person who rendered related services; any employer of the victim or claimant;

any police or governmental agency, including state or federal taxing authorities; any insurance company; or any organization having rele-

vant knowledge, to furnish to the Office of Victims' Services, Victims Compensation Assistance Program, any and all information in their

possession with respect to the crime that is the basis for this claim. Copies of this authorization may be used in place of the original.

________________________________________________________________

__________________________________

Claimant's Signature

Date

_______________________________________________________________________

______________________________________

Victim's Signature (if age 14 or over)

Date

Representation By Others

Are you represented in this matter by an attorney:

In filing this compensation claim?

In a civil lawsuit?

In an insurance action?

____yes ____no

Referral

Who referred you to the compensation program?

____Hospital

____Prosecuter

____Poster/Brochure

____ Police

____Victim Service Program

____Other (Identify)_____________________________________

Victim Service Program Information

For assistance in filing your claim, please call the agency listed here.

If no agency is listed, please call 1-800-233-2339 for assistance.

Victim Statistical Information

The following information is used for statistical purposes only. The submission of information for this section is strictly voluntary.

Race

____White ____Black ____Hispanic ____American Indian/Alaskan Native ____Asian/Pacific Islander ____Other

Country of Birth________________________________________

Do you have a disability?

____yes ____no

If yes, nature of disability ____Physical

____Mental ____Developmental Disability

Mailing Address:

Street Address:

P .O. Box 1167, Harrisburg, PA 17108-1167

3101 North Front St., Harrisburg, PA 17110

Phone and Fax Numbers: (800) 233-2339

(717) 783-5153

(717) 787-4306 (FAX)

Rev. 11/06

Website:

Pccd Victims Compensation Assistance Program Short Form Page 4

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