Victim Compensation Application - Mississippi Office Of The Attorney General Page 3
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4SECTION E – Loss of Support for Dependent(s)
Complete this information only if the victim financially supported dependent(s) at the time of death.
1. Did victim contribute financial support to any dependent at the time of death?
Yes
No If yes, list dependents (Attach additional sheet if necessary)
Name
Address – if different from
Social Security #
Relationship to
Date of Birth
claimant’s address
Victim
Month/Day/Year
2. Attach a copy of the victim’s latest income tax form and proof of dependency. (You may be asked for more information to
determine dependency and actual loss of support.)
SECTION F – Insurance and Other Collateral Source Information
By law, the Crime Victim Compensation Division is payer of last resort and must verify all sources available for payment of expenses. This
section must be completed. Please check each source that applies.
YES
NO
APPLIED FOR
N/A
1. Source
Health Insurance……………………………………………..
Automobile Insurance ……………………………………….
Social Security: SSI………………………………………….
Social Security: Disability……………………………………
Social Security: Death Benefits……………………………..
Workers’ Compensation………………………………………
Medicaid………………………………………………………..
Medicare………………………………………………………..
Veteran’s Administration……………………………………..
Unemployment Compensation………………………………
Disability Pay…………………………………………………..
Life Insurance…………………………………………….
Amount of Policy__________________________
Beneficiary_______________________________
Relationship to Victim______________________
Burial Insurance ……………………………………………
Amount of Policy__________________________
Donations for Funeral Expenses ………………………….
Amount__________________________________
Other (specify) _______________________________
2. Please list name, address and telephone number for each insurance company indicated above.
Insurance Company
Address
Telephone Number
3. If a car was involved in the crime, list the name and address of the offender’s automobile insurance company.
____________________________________________________________________________________________________
Page 3
Revised 6/2010
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