Claim Form - Delaware Victims' Compensation Assistance Program
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1
2
3CLAIM FORM
Complete and submit to:
Delaware Victims’ Compensation Assistance Program
900 North King St., Suite 4
Wilmington, DE 19801
Please contact the DE VCAP if you need assistance completing this form (Phone)302.255.1770 (Fax)302.577.1326
SECTION 1. VICTIM INFORMATION SECTION
Name of person injured or killed as the result of the violent crime. If there was more than one victim,
complete a separate claim form for each victim.
Victim’s Name (last, first, m.i.)
Date of Birth (MM/DD/YY)
Social Security Number
/
/
Gender
Race (optional)
Is Victim Deceased?
Male
Female
Asian/Pacific Island
American Indian/Alaska Native
Black
Yes
No
Hispanic
White
Other ___________________
Street Address (including apartment #)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
(
)
(
)
(
)
Who referred you to the compensation program?
Contact Person:______________________________________________________________________
Hospital
Police Agency
Prosecutor
Victim Services Police
Victim Services DOJ
Poster/Brochure/Advertisement
Public Service Announcement
Other:______________________
SECTION 2. CLAIMANT INFORMATION
Name of person filing on behalf of a deceased victim, minor victim, or an incapacitated adult victim.
Claimant’s Name (last, first, m.i.)
Date of Birth (MM/DD/YY)
Social Security Number
/
/
Gender
Relationship to Victim
Male
Female
Parent
Spouse/Partner
Former Spouse/Partner
Child
Sibling
Grandparent
Other __________________
Street Address (including apartment #)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
(
)
(
)
(
)
SECTION 3. CRIME INFORMATION
Date of Crime
Date Reported to Police
Name of Suspect
/
/
/
/
Relationship of suspect to victim: _______________________________________________________________________________________________
Name of Police Department Investigating Crime
Police Complaint Number
Investigating Officer’s Name
Location of Crime (address)
City
State
Zip Code
Type of Crime: (please check one)
Assault
DWI/DUI
Homicide/Murder
Child Sexual Abuse
Child Physical Abuse
Stalking
Kidnapping
Arson
Domestic Abuse
Adult Sexual Abuse
Robbery
Burglary
Protection From Abuse (PFA) or PFA ex parte (emergency hearing)
Other
Please specify if other: _______________________________
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