Ovs Claim Application And Instructions Page 3
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Application for Compensation
How to Apply for
New York State Office of Victim Services
Compensation before
filling out this form.
Please print. Answer all questions. It is a crime to file a false claim!
Victim Assistance Program Use Only
OVS VAP ID#
Program Name/Phone
Advocate Name/Email
Tell us about the victim.
1
Last Name
First Name
MI
Social Security #
Date of Birth
Check here if you do not have one.
__ __ __
-
__ __
-
__ __ __ __
Mailing Address:
Street
Apt. # (or P.O. Box)
City
County
State (or Foreign Country)
Zip Code
White
Black
Asian/Pacific Islander
Hispanic
American Indian/Alaskan Native
Other
Unknown
Race/Ethnicity:
Single
Married
Divorced
Separated
Widowed
Lives with partner
Marital Status:
Male
Female
Yes
No
Unknown
Gender:
Was the victim disabled at the time of the crime?
How did you first hear about the Office of Victim Services?
Police
Hospital
District Attorney
Victim Assistance Program
Radio/TV
Brochure/Poster
Internet
Other
If you are not the victim, and you are signing this claim, you are the claimant. Tell us about you.
(See “Who can sign
2
the claim?” on the instructions page.)
Last Name
First Name
MI
Social Security #
Date of Birth
Check here if you do not have one.
__ __ __
-
__ __
-
__ __ __ __
Mailing Address:
Street
Apt. # (or P.O. Box)
City
County
State (or Foreign Country)
Zip Code
What is your relationship to the victim?
Check only one.
(
)
Parent
Spouse
Child
Legal Guardian
Attorney
Other
(Explain):
Tell us about the crime.
(Check only one.)
3
The victim was injured
The victim died
because of:
The victim lost essential personal property
because of:
Assault
Stalking
because of
:
Motor Vehicle (DWI)
Sexual Assault
Kidnapping
Burglary/Robbery/Larceny
Arson
Motor Vehicle (Other)
Child Physical Abuse
Terrorism
Motor Vehicle (DWI)
Criminal Mischief
Terrorism
Child Sexual Abuse
Arson
Motor Vehicle (not DWI)
Arson
Motor Vehicle (DWI)
Robbery
Human Trafficking
Motor Vehicle (not DWI)
Human Trafficking
Human Trafficking
Other (Explain):
Other (Explain):
Other Homicide
:
Where did the crime happen?
(Check only one.)
Work
Owned residence
Apt. Bldg.
Public Street
Subway/Bus
Parking Lot
Restaurant/Bar
School/School grounds
Shopping Mall
Other (Explain):
Was this a domestic violence crime?
..................................................................
Yes
No
Unknown
Was the victim driving a livery cab when the crime happened?
............................
Yes
No
Unknown
Was the victim’s property lost or damaged while trying to prevent or stop a
crime against someone else or while helping the authorities stop the crime?
....
Yes
No
Crime Report #:
Police or criminal justice agency reported to:
_______________________________
________________
County where crime happened:
Date of crime:
Date crime was reported:
______________
______________
If more than 7 days between the date of crime and date the crime was reported, explain why:
____________________________________
_______________________________________________________________________________________________________________________________________________________________
If more than 1 year between the date of crime and the date you are filing this claim, explain why:
________________________________
_______________________________________________________________________________________________________________________________________________________________
Describe the crime in your own words:
____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
Rev. December 2013
Page 1 of 4
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