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

Did the victim miss time from work due to the crime? ___ Yes ___ No

If so, did the victim receive disability benefits or sick pay? ___ Yes ___ No

Has the victim returned to work? ___ Yes ___ No

If so, date: ____________________

SECTION VI – TUITION

(See Instructions for Section VI.)

Is tuition reimbursement claimed? ___ Yes ___ No

If so, list name of school/college/university: _________________________________________________________

Address: __________________________________________________________ Phone: ___________________

Semester(s) missed: _____________________________ Amount of tuition paid and unused: $ ______________

SECTION VII – SUBROGATION RIGHTS

(See Instructions for Section VII.)

740 ILCS 45/17, the Illinois Crime Victims Compensation Act, requires every applicant to subrogate to the State his

or her rights to collect damages from the assailant or other liable third parties.

Has a civil law suit been filed against any party with regard to this incident? ___ Yes ___ No

If so, please provide case number and county: _______________________________________

Has restitution been ordered against an offender? ___ Yes ___ No

If so, how much? $__________________

SECTION VIII. – CERTIFICATION & RELEASES

(See Instructions for Section VIII.)

Certification of Application: I hereby certify, subject to the penalties of perjury, that all of the information that I

have provided in this application is true, accurate and complete to the best of my knowledge.

Release of Information: I hereby authorize any hospital, physician, mental health provider, funeral director,

municipal, county or State authority, employer or union, insurance company, social service administrator, Social

Security office or any other individual, company or agency to release any and all information requested by the

Attorney General's Office in connection with this application.

Acknowledgment of Subrogation: I have read and understand Section VII, above, with regard to subrogation.

_______________________________________________________________ ____________________________

Applicant's Signature

Date Signed

740 ILCS 45/12 PROHIBITS LEGAL COUNSEL FROM CHARGING FEES FOR PRESENTING THIS FORM TO

THE COURT OF CLAIMS. IF, HOWEVER, THE APPLICANT IS REPRESENTED BY COUNSEL FOR THIS

CLAIM, PLEASE PROVIDE THE FOLLOWING:

Name of Attorney: ___________________________ Address: _________________________________________

Phone: ___________________________

ARDC No.: _______________

NOTE: Please list an alternate contact address and/or telephone number where you may be reached:

Name: ___________________________ Address: __________________________________________________

Phone: ___________________________

Please return completed application to the Crime Victims Compensation Bureau

Office of the Attorney General Lisa Madigan, 100 West Randolph Street, Chicago, Illinois 60601

Printed by authority of the State of Illinois. 04/05.5M.0830 This material is available in alternate format upon request.

PAGE 4

Crime Victims Compensation Application Page 4