Victim Compensation Application - Mississippi Office Of The Attorney General
ADVERTISEMENT
1
2
3
4For Office Use Only
OFFICE OF THE ATTORNEY GENERAL
CLAIM NO.___________________
Crime Victim Compensation Division
Received Date:
Post Office Box 220
Jackson, Mississippi 39205-0220
1-800-829-6766 or 601-359-6766
601-576-4445 (FAX)
(WEB)
VICTIM COMPENSATION APPLICATION
APPLICATION MUST BE COMPLETED, SIGNED AND NOTARIZED.
IT IS THE RESPONSIBILITY OF THE
VICTIM/CLAIMANT TO NOTIFY THIS DIVISION OF ANY CHANGES TO ADDRESS OR TELEPHONE NUMBERS.
Instructions
Please read the enclosed “General Eligibility Requirements” to see if you may qualify for this program. Fill
out this form completely (please print). Attach any required documentation, including all itemized bills, and
mail to the above address. If the victim is deceased, include itemized funeral burial expenses.
CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING:
Medical Expenses
Transportation (funeral)
R
h e
b a
t i l i
i t a
n o
Domestic Violence Relocation Assistance
Mental Health Counseling (victim)
Domestic Violence Temporary Housing Assistance
Mental Health Counseling (family member)
Court Related Travel Expenses
Transportation (Medical/MHC)
Crime Scene Cleanup Assistance
Funeral Expenses
Repair/Replacement Expenses
Loss of Wages (victim)
Loss of Wages (funeral)
Loss of Wages (claimant)
Loss of Support (dependents of deceased victim)
Loss of Wages (court proceeding)
SECTION A – Victim Information
A. Please type or print
B. A separate application must be completed
C. If a person witnessed the crime and is requesting mental
legibly with ink.
for each victim who received injuries.
health counseling, complete a separate application.
1. Victim’s Name ____________________________________________ 2. Marital Status
3. Mailing Address _______________________________________ 4. City/State/Zip
5. County ___________________ 6. Home Phone (
)
7. Work Phone (
)
8. Date of Birth: ______________ 9. Age: _________ 10. Social Security #:
11. E-mail Address:
12. Briefly describe your injuries:
13. The following information is used for statistical purposes only and is needed to comply with federal regulations.
A. Sex
Female
Male
D. Race:
Asian/Pacific Islander
B. Handicapped Before Crime
Yes
No
African American
Caucasian
C. Handicapped After Crime
Yes
No
Alaskan Native
Hispanic
American Indian
Other
Page 1
Revised 6/2010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application Form For Amusement Games License N.j.s.a. 5:8-100 Et Seq - New Jersey Office Of The Attorney General
Legal
Renewal Application For A Compensated Casino Night Employee (annually) Form - New Jersey Office Of The Attorney General
Legal
Non Attorney Employment Application Form - State Of New York, Office Of The Attorney General
Business
Initial Application Form For Bingo/raffle Equipment Providers, Instant Raffle Equipment Distributors/manufacturers, And Casino Night/armchair Race Equipment Providers - New Jersey Office Of The Attorney General
Legal
Verification Of Exemption From The Registration Requirements Under Minnesota Statutes Ch. 309 - Minnesota Office Of The Attorney General - 2000
Legal
Related Categories
Parent category: Legal