Fillable Application Minnesota Crime Victims Reparations Board The Minnesota (Minnesota)

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Application Minnesota Crime Victims Reparations Board The Minnesota (Minnesota)

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Instructions
Eligibility Requirements
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
possible.
•
Submit application as soon as possible. Additional
bills/documents can be sent later.
•
Complete a separate application form for each
victim.
•
A parent, guardian or relative must file the
application on behalf of a minor, incapacitated or
deceased victim.
•
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.
See below.
Office of Justice Programs
•
Victim of a crime in Minnesota or a
Mi
nnesota resident victimiz
ed
w
hile traveling in another country
•
Claim submitted within 3 years of
the crime (some exceptions apply)
•
Crime reported to police within 30
da
ys (exceptions for child abus
e
and s
exual assault)
•
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.
Expenses Covered
•
Medical/Dental
•
Counseling by a licensed provider
•
Mileage to medical/counseling appts.
•
Lost Wages
•
Funeral/Burial
•
Survivor’s benefits
•
Miscellaneous expenses (see
br
ochure)
*Caps/limits apply
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
dps.justiceprograms@state.mn.us
ojp.dps.mn.gov
Application
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.
1 of 6
Complete only if the person(s) submitting the application is not the victim.
This section must be completed by a parent, guardian or relative if the victim
is a minor, deceased or incapacitated.
SECTION 2. CLAIMANT INFORMATION
MINNESOTA CRIME VICTIMS REPARATIONS APPLICATION FORM
Date Received:
Complete and submit to:
Claim Number:
(Office Use Only)
Minnesota Crime Victims Reparations Board
445 Minnesota Street, Suite 2300
St. Paul MN 55101-1515
651.201.7300 or 1.888.622.8799 (Toll-Free)
651.296.5787 (Fax)
651.205.4827 (TTY)
dps.justiceprograms@state.mn.us
Claims Specialist:
(Office Use Only)
SECTION 1. VICTIM INFORMATION
Name of person injured or killed as the result of the violent crime. Complete a
separate application form for each victim.
Victim’s Name
(last, first, m.i.)
(MM/DD/YY) Social Security Number
None
Gender
Male Female
What is the language preference of the victim and/or claimant?
English Spanish Other
Is Victim Deceased?
No Yes
Address
City
State
Zip Code
Phone
Email Address
Claimant 1
Claimant’s Name
(last, first, m.i.)
Date of Birth
(MM/DD/YY)
Social Security Number
None
Gender
Male Female
Relationship to Victim
Parent Spouse/Partner Former Spouse/Partner Child Sibling
Grandparent Other
Address
City
State
Zip Code
Phone
Email Address
Claimant 2
Claimant’s Name
(last, first, m.i.)
Date of Birth
(MM/DD/YY)
Social Security Number
None
Gender
Male Female
Relationship to Victim
Parent Spouse/Partner Former Spouse/Partner Child Sibling
Grandparent Other
Address
City
State
Zip Code
Phone Email Address
SECTION 3. REFERRAL SOURCE
How did you learn of the reparations program?
County Attorney
Domestic Abuse Program
Funeral Home
Hospital
Police
Probation
Sexual Assault Program
Social Services, Cleric or School
Victim Assistance Program
Website
Other
2 of 6
SECTION 4. CRIME INFORMATION
Date of Crime
Date Reported to Police
County Where Crime Occurred
Police Department
Police Case Number
Investigating Officer’s Name
Did the crime involve? Domestic or Family Violence Bullying Elder Abuse Hate Crime Mass Violence
Type of Crime (check all that apply) Child Physical Abuse DWI Burglary
Assault Child Sexual Abuse Other Vehicular Crime Fraud/Financial Crime
Homicide Child Pornography Stalking Terrorism
Robbery Human Trafficking Arson Other
Adult Sexual Assault Kidnapping
Briefly describe crime and injuries. Attach additional pages if necessary.
Name of Offender(s)
(last, first, m.i.)
Gender Male Female
Date of Birth
(MM/DD/YY)
SECTION 5. FEDERAL
REPORTING INFORMATION
The following voluntary information is for the victim for whom this application was
filed and is used for statistical purposes only to comply with federal regulations.
Ethnicity Black/African Hispanic/Latino
American Indian/ American Multi-
Racial Alaskan Native
Hawaiian/Other Other
Asian Pacific Islander White
Country of Birth
Was the victim disabled prior
to the crime?
No Yes
SECTION 6. AUTHORIZED CONTACT
INFORMATION
Your claim is confidential. If you would like the Board to be able to discuss
your claim with anyone (parent, spouse, social worker) you must list their
information below.
Name
Relationship to you
Phone
Name
Relationship to you
Phone
SECTION 7. REPRESENTATION BY OTHERS
The Board is authorized to release private and confidential data about
this claim to the representatives listed below.
ATTORNEY INFORMATION
VICTIM ASSISTANCE PROGRAM INFORMATION
Are you represented in this matter by a private attorney?
No Yes
Are you working with an advocate?
No Yes
Name of Attorney
Name of Advocate
Law Firm
Victim Assistance Program
Address
Address
City
State
Zip Code
City
State
Zip Code
Phone
Fax
Phone
Fax
3 of 6
Complete if the victim and/or claimant lost income due to the crime. Your employer
will be contacted to verify your wage loss.
SECTION 9. LOSS OF
EARNINGS
SECTION 8. OTHER SOURCES OF PAYMENT
All bills must first be submitted to your insurance company. The
Board may deny payment if you fail to use other available sources.
Was there insurance or another source of payment to cover expenses related to the crime?
No
Yes
Check all that apply
Automobile Insurance Homeowner’s Insurance Medicare Veteran’s Benefits
Dental Insurance Long/short term Disability MNSure Worker’s Compensation
Health Insurance Medical Assistance (MA) Social Security Disability Other
Complete for all other sources available to pay for crime related expenses, or attach a copy of insurance card.
Insurance company
Address
Phone
Policy
Group
Insurance company
Address
Phone
Policy
Group
Insurance company
Address
Phone
Policy
Group
ATTACH INSURANCE EXPLANATION OF BENEFITS FOR ALL PAYMENTS AND/OR DENIALS
Victim Employment Information
Were you employed
on date of crime?
No Yes
Were you self-employed on the date of the crime?
No Yes
If yes, attach a copy of your most recent federal tax return
Your Occupation/Job Title
Employer’s Business Name
Supervisor’s Name
Phone
Fax
Address
City
State
Zip Code
First Date Missed
Date Returned
Did the crime occur while you were on the job?
No Yes
Did you receive any benefits for time missed from work? No Yes
Disability Workers Compensation Sick Leave Vacation Pay Other (explain)
Doctor/Counselor who can verify disability
Hospital/Clinic
Address
Claimant Employment Information (If more than 1, attach a separate sheet with all requested information.)
Claimant’s Name
Were you self-employed on date of crime? No Yes
If yes, attach a copy of your most recent federal tax return
Employer’s Business Name
Phone
Fax
Your Occupation/Job Title
Address
City
State
Zip Code
First Date Missed
Date Returned
Why did you miss work? To provide care to victim
Medical/counseling appts.
Emotional injury from crime
Did you receive any benefits for time missed from work? No Yes
Disability Workers Compensation Sick Leave Vacation Pay Bereavement Other (explain)
4 of 6
SECTION 10. MEDICAL AND
DENTAL EXPENSES
List the healthcare providers who treated crime related injuries, including
pharmacies. Attach itemized bills and receipts, if available. Providers must
also be listed on the release form on page 6.
Provider
Address
Phone
Provider
Address
Phone
Provider
Address
Phone
Provider
Address
Phone
SECTION 11. MENTAL HEALTH
COUNSELING EXPENSES
List the mental health providers who treated the victim and/or claimant. Attach
itemized bills if available. Unlicensed providers are not covered. Providers
must also be listed on the release form on page 6.
Patient
Counselor/Clinic
Address
Phone
Patient
Counselor/Clinic
Address
Phone
Patient
Counselor/Clinic
Address
Phone
COMPLETE SECTIONS 12 & 13 ONLY IF THE VICTIM DIED AS A RESULT OF THE CRIME
SECTION 12. FUNERAL EXPENSES
List all funeral homes/cemeteries that provided services. Attach a copy of
funeral and burial contracts, if available. Attach receipts if you had travel/lodging
expenses to attend the funeral.
Funeral Home/Cemetery
Address
Phone
Funeral Home/Cemetery
Address
Phone
SECTION 13. LOSS OF SUPPORT FOR
DEPENDENTS OF DECEASED VICTIMS
Loss of support benefits are paid to dependents (spouse/partner, minor
children) of the deceased victim. The legal guardian must file on the minor
child’s behalf.
Was the victim providing support to a spouse/partner at the time of his/her death? No Yes
Spouse/Partner
Address
Phone
Does the victim have dependent children under the age of 18? No Yes
Child
Guardian
Address
Phone
Child
Guardian
Address
Phone
Child
Guardian
Address
Phone
5 of 6
SUBSTITUTE FORM W-9
Name and Address
400 Centennial Building
658 Cedar Street
St. Paul, MN 55155
Fax: (651) 797-1306
Vendor.mmbefax@state.mn.us
Date:
Vendor Number:
SUBJECT: Request for taxpayer Information. (Failure to furnish a taxpayer identification number makes you subject
to a penalty of $50.
The purpose of
this form is to obtain or confirm your correct taxpayer name and identification number. Federal and state
tax regulations require that we have this information from recipients of certain payments in order to report such payments
to the Internal Revenue Service on the Form 1099 Return.
Please complete items 1, 2, and 3 below. If you have any questions, phone (651) 201-8201 for assistance. Send, fax or e-mail
the completed form to the address in the upper right corner.
1. Check your ta
x filing status below and enter your social security number or federal employer identification number. If
you have been issued a separate Minnesota tax identification number, write it in the space provided.
If you have
recently applied for a taxpayer number, write “Applied For” in the space for the number.
(Check One)
Individual: Use SSN
Sole Proprietorship: Use SSn or FEIN
____________________________
SOCIAL SECURITY NUMBER (SSN)
Corporation: Use FEIN
S Corporation
Legal Exempt Organization: Use FEIN and list the
______________________________
FEDERAL EMPLOYER IDENTIFICATION (FEIN)
section number of the IRS code under which you are
Claiming exemption: ______________________
Other: Please explain on reverse side and include a
________________________________
MINNESOTA TAX I.D. NUMBER (IF APPLICABLE)
tax number.
2. Print the full name belonging to the social security number or employer identification number written above.
______________________________________________________________________________________________
3. Certification. Under penalty of perjury, I certify the number shown on this form is my correct taxpayer identification
number.
Signature_____________________________________ Phone No.:______________________ Date________________
PRIVACY ACT NOTICE – Internal Revenue Code Section 6109requires you to furnish your correct taxpayer
identification number to payers who must file information returns with IRS. IRS uses the numbers for identification
purposes and to help verify the accuracy of your tax return. Payers must generally withhold 28% of taxable interest
and certain other payments to a payee who does not furnish a TIN to a payer.
(Rev. 6/20)
COMPLETE SECTIONS 15 AND 18
SECTION 14. ASSIGNMENT OF
SUBROGATION RIGHTS
I agree that the Board is subrogated to the extent of reparations awarded and to all my rights to recover benefits for economic loss from another source.
I assign such rights to the Board so that they may protect their subrogation interest. I agree to inform the Board in writing if I pursue a civil suit or receive
any restitution moneys related to the crime.
SECTION 15. INFORMED CONSENT TO
RELEASE PATIENT INFORMATION
, I consent to the release of all patient health care records for , Date of Birth
including reports of alcohol or drug abuse and psychiatric treatment, to the Minnesota Crime Victims Reparations Board from all providers of medical
and mental health treatment services, including but not limited to the providers listed below. I authorize CVRB staff to complete this section on my
behalf, if necessary.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
The consent to release patient information covers the time period of: to:
SECTION 16. AUTHORIZATION TO OBTAIN
AND RELEASE INFORMATION
I authorize any law enforcement agency, employer, insurance company, social service agency, victim advocacy program, county, state or federal
prosecutor’s office, or any other federal, state or local government agency to release all records and information that the Board determines will help in
deciding my eligibility or level of benefits in this claim. I specifically authorize the Minnesota Department of Revenue to release a copy of my tax returns
to the Board for the purpose of determining my lost wages.
I authorize the Minnesota Crime Victims Reparations Board to release private and confidential data about my claim to the court administrator,
prosecutor, and any officers of the court and probation and parole officials for the purpose of assessing the economic impact of the crime upon me and
for determining the amount of restitution to be paid by the offender.
I authorize the Board to release private and confidential data about my claim to a local Emergency Fund administrator for the purpose of coordinating
benefits.
SECTION 17. MISCELLANEOUS
CONSENTS/AGREEMENTS
I agree that any reparations awarded may be paid directly to the provider of the service on my behalf.
I understand that authorizing the disclosure of health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to
assure treatment by a health provider.
I understand that my refusal to provide information or not allow access to information needed to analyze my claim may result in the denial of
reparations.
I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the redisclosure of protected health
information may not be protected by federal privacy rules.
This consent will remain in effect for one year from the date of my signature. I consent to the release of healthcare records created after the date of my
signature below. I understand that I may revoke this authorization at any time by submitting a written notification to the Board. This revocation will not
apply to information that has already been released in response to this authorization.
A photocopy of this consent form may be accepted as the original.
SECTION 18. VICTIM AND CLAIMANT
SIGNATURES
The victim must sign and date the application form. If the victim is deceased, under the age of
eighteen or an incapacitated adult victim, the claimant must sign and date the application form.
I have read and understand the statements in Sections 14-17 above. I hereby certify that the information
contained in this application is true and correct to the best of my knowledge. I understand that it is a gross
misdemeanor to knowingly file a false claim.
Victim/Patient Signature
Victim/Patient Printed Name
Date of Birth
Date Signed
Claimant 1 Signature
Claimant Printed Name
Date of Birth
Date Signed
Claimant 2 Signature
Claimant Printed Name
Date of Birth
Date Signed
Claimant 1’s relationship to victim
Claimant 2’s relationship to victim
Reason victim cannot sign claim form
Deceased Minor Incapacitated Adult
6 of 6
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Application Minnesota Crime Victims Reparations Board The Minnesota (Minnesota)

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Completed 30 January 2021

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