Crime Victims Compensation Application printable pdf download

CRIME VICTIMS COMPENSATION APPLICATION

STATE OF ILLINOIS

COURT OF CLAIMS

ATTORNEY GENERAL

PLEASE READ ATTACHED INSTRUCTION SHEET AND USE BLACK INK OR TYPE.

For HELP call the Attorney General's Office at 312-814-2581 or 1-800-228-3368.

SECTION I. – CLAIMANT & VICTIM INFORMATION

(See Instructions for Section I.)

CLAIMANT (IF NOT VICTIM)

Claimant's Name: ___________________________________ Date of Birth: __________

___ Male ___ Female

Street Address: _____________________________________________________________________________

City: _____________________________________________ State: ________ Zip Code: __________________

Home Telephone: _____________________ Work/Other Daytime Telephone(s): _____________________

Social Security No.: _____________________ Relationship to Victim: _____________________

VICTIM

Victim's Name: _____________________________________ Date of Birth: __________

___ Male ___ Female

Street Address: ______________________________________________________________________________

City: _____________________________________________ State: ________ Zip Code: __________________

Home Telephone: ____________________ Work/Other Daytime Telephone(s): ____________________

Social Security No.: ___________________ Marital Status: ___ Single ___ Married ___ Divorced ___ Widowed

Does the victim suffer from an actual or perceived disability that substantially limits activity? ____ Yes ___ No

THE FOLLOWING INFORMATION IS USED FOR STATISTICAL PURPOSES ONLY IN COMPLIANCE WITH

FEDERAL REGULATIONS. PROVIDING THIS INFORMATION IS VOLUNTARY AND WILL NOT AFFECT

YOUR APPLICATION.

Ethnic Group: ___ Black (not Hispanic)

___ White (not Hispanic)

___ Hispanic (any Spanish culture) ___ American Indian or Alaskan Native

___ Asian or Pacific Islander (including Indian subcontinent)

How did you learn about Crime Victims Compensation? _______________________________________________

SECTION II. – CRIME INFORMATION

(See Instructions for Section II.)

Date of Crime: _________________ Date Crime Reported: ___________ Police Report No.: ________________

Street Address where crime occurred: _____________________________________________________________

City: _______________________________________________________________ County: ________________

Name of Agency/Department crime reported to: _____________________________________________________

City: _______________________________________________________________ County: ________________

PAGE 1

Crime Victims Compensation Application