Ovs Claim Application And Instructions Page 4

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4
Tell us about the suspect.
Suspect’s name (if you know):
Has the suspect been arrested for this crime?
..................
Yes
No
Has the suspect been prosecuted for this crime?
..............
Yes
No
Not Yet
Does the suspect live in the same house as the victim
OR is the suspect a member of the victim’s family?
..........
Yes
No
Has the court issued an order of protection in this case?
..
Yes
No (If Yes, attach a copy.)
Has the DA asked the court to order restitution?
Yes
No
Not Yet
Did the court order the suspect to pay restitution?
............
Yes (Amount $ _________ )
No
Not Yet
NOTE - If you are eligible for compensation, the OVS may be able to reimburse for the expenses listed below. These items should also be
requested as part of court ordered restitution. Applicants are encouraged to share this information with prosecutors if there is a criminal
case. See the Court Ordered Restitution Information page for important information about restitution.
5
Tell us about your expenses related to this crime.
(Check all that apply.)
Medical/Ambulance
Loss of Support
Lost Wages
Personal Transportation
Crime Scene Cleanup
(Death Claim Only)
DV Shelter
Medical
Security Device/System
Vocational/Rehabilitation
Moving/Storage
Court
Counseling
Funeral/Burial
Essential Personal Property
Other (Explain):
6
List any essential personal property, like cash, eyeglasses, or clothing that needs to be replaced
because of this
crime.
(If none, skip to 7.)
Describe what was lost/damaged:
Cost
Describe what was lost/damaged:
Cost
1.
$
4.
$
_________________________________________________
______________________
_________________________________________________
__________________________
2.
$
5.
$
_________________________________________________
______________________
_________________________________________________
__________________________
3.
$
6.
$
_________________________________________________
______________________
_________________________________________________
__________________________
Homeowner/Renter Insurance Company
Policy or ID #
Deductible
$
Auto/Other Insurance Company
Policy or ID #
Deductible
$
— If there were no injuries and you are only asking for essential personal property benefits, skip to 15. —
7 Tell us about the victim’s or the parent’s employment and insurance for Lost Wages.
If you do not want us to contact your employer, you cannot ask to be reimbursed for Lost Wages. (Skip to 8.)
Was the victim/parent of hospitalized minor victim employed when the crime happened?
Yes
No (If No, skip to 8.)
Did the victim/parent of hospitalized minor victim miss work because of the crime?
Yes
No
No (If Yes, attach copies of last year’s federal tax return and all schedules.)
Was the victim/parent self-employed?
Yes
Employer’s Name, Address, and Phone #:
(
)
Employer
Street
City
State
Zip Code
Phone #
Other Employer’s Name, Address, and Phone #:
(
)
Employer
Street
City
State
Zip Code
Phone #
Name, Address, and Phone # of doctor who certified victim could not go to work:
(
)
Doctor
Street
City
State
Zip Code
Phone #
Tell us about any insurance company that will cover the victim’s lost time at work. (If none, write “None” below and skip to 8.)
Policy or ID # or “None”
Policy or ID # or “None”
5. Workers’ Compensation
1. Unemployment Insurance
2. Disability Insurance
6. Other insurance
3. Pension Plan
7. Social Security Benefits (ssn
SSN
required)
__ __ __
-
__ __
-
__ __ __ __
8. SSI Benefits (ssn required)
SSN
4.
Other insurance
__ __ __
-
__ __
-
__ __ __ __
8
If the victim died, fill out below if you have any burial expenses.
(If not, skip to 9.)
Also, attach a copy of the funeral home contract, other bills for burial expenses, and a photocopy of the Death Certificate, if you have them.
Phone #:
(
)
Name of Funeral Home:
Telephone #:
Address:
Street
City
State
Zip Code
Rev. December 2013
Page 2 of 4

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