Application For Crime Victim Reparations (Page 2 of 2) in pdf

Section 6. REFERRED BY

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Police Agency

Medical Doctor

Non-profit service agency

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Police Agency Victim Advocate

Hospital

Other ______________________________

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Prosecuting Agency

Dentist

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Prosecuting Agency Victim Advocate

Mental Health Counselor

Section 7. BENEFITS

(Check as many as apply)

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Relocation and related expenses

Medical care

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Dental care

Rent (Family Violence/Child Abuse Claims Only)

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Loss of earnings due to the crime

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Replacement services loss (example: child care, convalescent care,

meal preparation, house cleaning/laundry)

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Mental health counseling

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Eye glasses, hearing aids or other medically necessary devices

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Loss of support to dependents (Homicide Claims Only)

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Replacement of door locks or windows

Funeral and burial expenses

Section 8.

I M P O R T A N T

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P L E A S E

R E A D

C A R E F U L L Y

Assignment of Recovery

I understand that any recovery of my losses from the offender through court-imposed restitution or civil lawsuit, from any insurance or from any other

governmental or private agency shall entitle the OFFICE OF CRIME VICTIM REPARATIONS to reimbursement of any compensation awarded to me

and I hereby assign such recovery to the OFFICE OF CRIME VICTIM REPARATIONS. I agree to notify a representative of the OFFICE in the event I

recover any of my losses or in the event I initiate any legal proceedings or negotiations to recover my losses

Claimant/Victim Authorization

I hereby authorize the release of any information deemed necessary by the OFFICE OF CRIME VICTIM REPARATIONS for a determination of the

eligibility of this claim for benefits. A photocopy of this authorization is as effective and valid as the original.

Private and Controlled Records

The OFFICE OF CRIME VICTIM REPARATIONS may ask you to provide information that is classified as private or controlled under the Government

Records Access and Management Act. Such information will be used to evaluate the eligibility of your application and your eligibility for specific benefits

and may be shared with law enforcement agencies, prosecuting agencies, medical providers, and mental health providers. The OFFICE OF CRIME

VICTIM REPARATIONS may also share information regarding payments made on your behalf with a court to facilitate an order of restitution. You may

refuse to provide private or controlled information; however, refusal to provide such information may result in the denial of your application or the denial

of specific benefits if your application is approved.

Declaration

Pursuant to Utah Code Annotated, Section 63-25a-410(2), a person who knowingly submits a fraudulent claim for reparations or who knowingly

misrepresents material facts in making a claim, is guilty of an offense punishable by fine or imprisonment. The undersigned swears or affirms that the

information contained herein is true to his or her best knowledge.

Date: _______________________ Victim or Claimant Signature ______________________________________________________________________

APPLICATIONS SUBMITTED FOR CHILD VICTIMS UNDER THE AGE OF EIGHTEEN MUST BE COMPLETED

AND SIGNED BY THE CHILD’S PARENT OR LEGAL GUARDIAN

For Americans with Disabilities Act Accommodations, please contact the Office of Crime

Victim Reparations at (801)238-2360 allowing three working days notice.