Application For Crime Victim Reparations

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State of Utah
DO NOT WRITE IN THIS SPACE
OFFICE OF CRIME VICTIM REPARATIONS
File #1: _______________________
350 East 500 South Suite 200
File #2: _______________________
Salt Lake City Utah 84111
(801) 238-2360 or Toll Free 1-800-621-7444
File #3: _______________________
Fax (801) 533-4127
File #4: _______________________
File #5: _______________________
APPLICATION FOR CRIME VICTIM REPARATIONS
Section 1. VICTIM INFORMATION
Victim Name/s
Date of Birth
Sex (M/F)
Social Security #
Disabled (Y/N)
Race
(1) __________________________________________________________________________________________________________________________
(2) __________________________________________________________________________________________________________________________
(3) __________________________________________________________________________________________________________________________
(4) __________________________________________________________________________________________________________________________
Street Address: _______________________________________________________________________________________________________________
City:____________________________________ State:____________________ County:_______________________ Zip: _______________________
Phone Number:
Home: (
) _________________ Work: (
) _________________
Section 2. CLAIMANT INFORMATION
(to be completed only if the claimant is not the victim)
Claimant Name
Date of Birth
Sex (M/F)
Social Security #
Disabled (Y/N)
Race
_____________________________________________________________________________________________________________________________
Street Address: _______________________________________________________________________________________________________________
City:____________________________________ State:____________________ County:_______________________ Zip: _______________________
Phone Number:
Home: (
) _________________ Work: (
) _________________
Claimant Relationship to Victim:
Spouse
Parent
Sibling
Child
Other ___________________________________
Section 3. CRIME INFORMATION
Law Enforcement Agency: ________________________ Law Enforcement Case Number:___________________ Crime Date: ____________________
Brief Description of Crime: ______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Complete Address of Crime: Street Address: _____________________________ City:__________________ State:_______ County: ______________
Offender Name: __________________________ Has the offender been charged in court? Yes
No
Type of weapon used: ___________________
Section 4. INSURANCE
(Failure to provide this information may delay processing of the application)
Does the victim or claimant have: Health Insurance
Medicaid
Auto Insurance
Social Security
Other _________________________
Name of Health Insurance Provider ________________________________ Name of Auto Insurance Provider ___________________________________
Policy Number ________________________________
Policy Number ________________________________
Has a civil law suit or insurance action been filed for this claim?
Yes
No
Attorney’s Name ______________________________________________ Phone Number: (
) _____________________________________________
________________________________________________________________________________________________________________________________________________________________
Section 5. EMPLOYMENT
Were you employed at the time of the crime? Yes
No
Employer’s Name _____________________________ Phone: (
) _______________
Employer’s Address: Street: ____________________________________________ City:_____________________ State:______ Zip: ______________
Revised 10-2008

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