Crime Victims Compensation Application (Page 2 of 4) in pdf

Crime Victims Compensation Application Page 2

Describe crime: ______________________________________________________________________________

___________________________________________________________________________________________

Name of offender, if known: __________________________ Was offender arrested? ___ Yes ___ No ___ Unk

Has offender been charged in court? ___ Yes ___ No ___ Unk If so, what is the charge? _________________

Criminal Case No.: ___________________ Circuit Court of: ______________ County Court Date: __________

SECTION III. – MEDICAL INFORMATION & BENEFITS

(See Instructions for Section III.)

Are medical expenses claimed? ___ Yes ___ No

Are counseling expenses claimed? ___ Yes ___ No

Describe the injuries: ___________________________________________________________________________

List the names and addresses of all doctors, hospitals, counselors or other medical service providers who treated

the victim for injuries arising from the crime as described above.

Medical Provider

Address

Date(s) of Service

Amount of Bill

Are further medical expenses anticipated? ___ Yes ___ No

Please indicate what sources of payment are available to cover the above listed charges:

Source

Unk

Yes

Benefit Provider's Name

Private, Group, Employer, or Union Health Insurance

Public Aid or AFDC

Medicare or Medical Assistance

Workers Compensation

Veterans Administration, Champus

SSI or SSDI

Proceeds of Personal Injury or other Litigation

If the victim has received or may receive direct payment from any of the following sources, please list:

Source

Yes

Monthly Amount

Paid From (date)

Paid To (date)

Public Aid or AFDC

SSI or SSDI

Other (specify)

Table continued on Page 3.

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Crime Victims Compensation Application Page 2