If you need help completing this application form, contact
our office or your local victim assistance program. Visit our
website for a listing of victim assistance programs. Please
read the following before completing the form:
Print clearly and provide as much information as
Submit application as soon as possible. Additional
bills/documents can be sent later.
Complete a separate application form for each
A parent, guardian or relative must file the
application on behalf of a minor, incapacitated or
Include copies of all expenses (medical bills,
receipts, insurance statements), if available.
Complete the W9 form (page 5) for the person who
may receive a direct payment.
Sign and date the release form (page 6). The time
period in Section 15 should cover from the crime
date through the last expected treatment date.
Mail, fax or email your completed application form.
Office of Justice Programs
Victim of a crime in Minnesota or a
nnesota resident victimiz
hile traveling in another country
Claim submitted within 3 years of
the crime (some exceptions apply)
Crime reported to police within 30
ys (exceptions for child abus
Victim/claimant cooperated fully
with police and prosecution
Victims who contributed through
serious misconduct or criminal
activity may be disqualified or
receive reduced benefits.
*There are other factors not listed that
might make you ineligible.
Counseling by a licensed provider
Mileage to medical/counseling appts.
Miscellaneous expenses (see
Crime Victims Reparations Board
445 Minnesota Street, Suite 2300•St. Paul, MN 55101
651-201-7300•888-622-8799•Fax 651-296-5787•TTY 651-205-4827
Minnesota Crime Victims Reparations Board
The Minnesota Crime Victims Reparations Board provides financial assistance to victims of
violent crime and their family members for related expenses that cannot be reimbursed by
insurance or other sources. Expenses for damaged/stolen property are not covered.