Crime Victim Justice Unit Complaint Form
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Minnesota Department of Public Safety
Office of Justice Programs
CRIME VICTIM JUSTICE UNIT COMPLAINT FORM
F
OR OFFICE USE ONLY
INSTRUCTIONS:
PLEASE FILL OUT ALL FOUR PAGES. BE SURE TO SIGN BOTH
CVJU CASE
PAGES 3 AND 4. ATTACH COPIES (NOT ORIGINALS) OF RELEVANT DOCUMENTS.
NUMBER
RETURN FORM TO THE CVJU AT THE ADDRESS BELOW. PLEASE NOTIFY THE
CVJU IF YOU CHANGE YOUR ADDRESS OR PHONE NUMBER.
Crime Victim Justice Unit
445 Minnesota Street, Suite 2300
St. Paul, MN 55101
1.800.247.0390 ext. 3
Local: 651.201.7310
Fax: 651.296.5787
TTY: 651.205.4827
S
1. V
I
ECTION
ICTIM
NFORMATION
Victim's Name (Last, First, & MI):
Is the Victim Deceased?
Date of Birth
:
Gender:
)
(Month/Day/Year
No
Yes
Female
Male
Street Address (Including Apt #):
City:
State:
Zip Code:
Home Telephone Number:
Work Telephone Number:
Cell Phone Number:
Contact Name
E-mail Address:
(Another person we can contact to
Contact Phone Number:
reach you):
What is the preferred contact method during the day?
Home phone
Cell phone
Work phone
Any phone
E-mail
N/A
S
2. P
(
)
ECTION
ERSON MAKING COMPLAINT TO CVJU
COMPLAINANT
(Complete only if different than above.)
Complainant's Name (Last, First, & MI):
Date of Birth:
City:
State:
Gender:
Street Address (Including Apt #):
Zip Code:
Female
Male
Home Number:
Work Number:
E-mail Address:
Cell Number:
Your relationship to the victim:
Contact Name
Contact Phone Number:
(Another person we can contact to reach you):
(spouse, parent, etc.)
Home phone
Cell phone
Work phone
Any phone
E-mail
N/A
What is the preferred contact method during the day?
S
3. R
S
ECTION
EFERRAL
OURCE
Please tell us how you learned of the Crime Victim Justice Unit.
Prosecutor
Domestic Abuse
Hospital
OJP Web Site
(County or City Attorney)
Program/Shelter
Social Services
Brochure
Private Attorney
Sexual Assault Program
Legislator
TV or Radio
Minnesota Attorney General
Victim/Witness
Assistance Program
Police
Funeral Director
Telephone Book
Other Advocate
Probation
Crime Victim Services
Newspaper
Crime Victims
Family/Friend
Other (please note)
Reparation Board
Crime Victim Justice Unit Complaint Form
Page 1
Rev: 11-08
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Parent category: Legal