Fillable Application for Crime Victim Compensation Section 1 Claimant

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Application for Crime Victim Compensation Section 1 Claimant

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FIRST NAME:
MIDDLE NAME: LAST NAME:
GENDER:
Relationship to victim:
DATE OF BIRTH
(MMDDYYYY):
STREET NUMBER AND NAME OR P.O. BOX:
Address 2 (Apartment or Unit #): CITY: STATE: ZIP:
HOME TELEPHONE:
WORK TELEPHONE:
Ext.
CELL PHONE:
E-MAIL:
E-MAIL TYPE:
If you are an adult victim and the
Application for Crime Victim Compensation
A separate application must be filed for each person seeking assistance.
Section 1 must be completed for all applications. The claimant is the person who has expenses or is seeking assistance as a
result of a crime. If you are filing this application on behalf of someone else, put their information in Section 1 and your
information in Section 3.
From the date of the crime to the present, has the claimant been in prison,
on probation, or on parole because of a felony?
If not, continue to Section 2
Crime VictimSection 2
The crime victim is the person who was injured, threatened with injury, or killed due to the crime.
If not, skip to Section 4
If you are completing this application on behalf of a minor or an incapacitated adult, continue to Section 3
Section 1 Claimant
ASSOCIATED
APPLICATION ID:
Enter if known
Page 1 of 6STATE OF CALIFORNIA CALIFORNIA VICTIM COMPENSATION PROGRAM FORM VCGCB-VCP-005 (Rev. 12/12) [ENG]
Mailing Address
FIRST NAME:
MIDDLE NAME: LAST NAME:
GENDER:
DATE OF BIRTH
(MMDDYYYY):
IF VICTIM IS DECEASED,
DATE OF DEATH (MMDDYYYY):
STREET NUMBER AND NAME OR P.O. BOX:
Address 2 (Apartment or Unit #): CITY: STATE: ZIP:
HOME TELEPHONE:
WORK TELEPHONE:
Ext.
CELL PHONE:
E-MAIL:
E-MAIL TYPE:
From the date of the crime to the present, has the victim been in prison,
on probation, or on parole because of a felony?
Mailing Address
SOCIAL SECURITY # (No dashes):
Does the victim have a Social Security number?
SOCIAL SECURITY # (No dashes):
Does the claimant have a Social Security number?
expenses are for you, skip to Section 4
Check This Box if You Are a Parent/Guardian Applying on Behalf of a
Minor Witness to Violent Crime. Minor witnesses are eligible for mental
health treatment only. Claimant is under age 18, a witness in close proximity to
a violent crime, but is neither the crime victim nor related to the victim. Provide
available victim, crime or other information in remaining sections.
CA
CA
Parent or Guardian (Applicant)Section 3
This section is for parents or guardians of minors or incapacitated adults in Section 1.
Please indicate your relationship to the person listed in Section 1:
FIRST NAME:
MIDDLE NAME: LAST NAME:
GENDER:
DATE OF BIRTH
(MMDDYYYY):
STREET NUMBER AND NAME OR P.O. BOX:
Address 2 (Apartment or Suite #): CITY: STATE:
ZIP:
HOME TELEPHONE:
WORK TELEPHONE:
Ext.
CELL PHONE:
E-MAIL: E-MAIL TYPE:
Medical and/or
dental expenses
Mental health treatment
Income loss
(if you missed work because of the crime)
Moving or
relocation expenses
Home security improvements
Home or vehicle modifications
(for a victim disabled because of the crime)
Job retraining
(for a victim disabled because of the crime)
Crime scene clean-up
Other crime-related expense(s):
Mental health treatment
Wage loss
(up to 30 days if a minor dies or is hospitalized)
Loss of support
(for dependents of a deceased or disabled victim)
Funeral and/or
burial expenses
Crime scene clean-up Home security improvements
Yes
For the victim of the crime, the following benefits may be available. Please check the crime-related expenses you are
requesting. Please attach copies, or a list, of any crime-related bills.
For someone other than the victim of the crime, the benefits below may be available. Please check the crime-related
expenses you are requesting. Please attach copies, or a list, of any crime-related bills.
EMERGENCY AWARD REQUEST:
Emergency awards may be requested in certain situations. An emergency award is intended to pay for crime-related expenses in cases
where you will suffer serious financial hardship if crime-related expenses are not immediately paid. Substantial hardship means you would
not have any money left for necessities like food or rent after you paid for crime-related bills. Qualifying emergency awards are generally paid
within 30 calendar days of receipt of the application.
Does the applicant have a Social Security number?
From the date of the crime to the present,
have you been in prison, on probation, or on
parole because of a felony?
Mailing Address
Do you need to request an emergency award?
Continue to Section 4
Section 4 Information About Your Expenses
SOCIAL SECURITY # (No dashes):
Medical expenses for a deceased victim
Continue to remaining sections
For minor witnesses to violent crime, only mental health benefits are available. Proceed to Section 5.
CALIFORNIA VICTIM COMPENSATION PROGRAM Page 2 of 6STATE OF CALIFORNIA FORM VCGCB-VCP-005 (Rev. 12/12) [ENG]
CA
Section 5 Crime Information
NAME OF THE LAW ENFORCEMENT AGENCY TO WHICH THE CRIME WAS REPORTED:
FROM: TO:
DATE CRIME WAS REPORTED:
TYPE OF CRIME:
CRIME REPORT NUMBER:
COUNTY WHERE CRIME OCCURRED:
Address, Intersection, Area, etc: Address 2 (Apt or Ste #): CITY: STATE: ZIP:
FIRST NAME:
MIDDLE NAME:
LAST NAME:
DESCRIBE INJURIES:
ORGANIZATION NAME:
TAX ID:
STATE BAR #:
TELEPHONE:
Ext.
FIRST NAME: MIDDLE NAME:
LAST NAME:
STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY:
STATE:
ZIP:
Medical Provider Children’s Protective Services
Mental Health Provider
Victim Witness Assistance Center
Adult Protective Services
Card or Booklet
Media (TV, Radio, Newspaper, etc.)
Billboard or Poster Other:
Person who committed the crime (suspect), if known
Section 6 Representative Information (A representative is not needed to apply for victim compensation.)
Attorney/Representative's signature: Date:
This section is for representatives only, including victim advocates and attorneys. Victim Assistance Center Advocates need
only provide phone, name, center #, sign and date. Attorneys, please fill out this section completely.
Section 7
How Did You Find Out About the Program?
Law Enforcement Agency Name Date(s) crime occurred
If on one day,
enter here
\
Mailing Address
For Attorneys Only: For Victim Assistance Center Staff Only:
JP/VWC #:
Signature and date required for all representatives
Are you requesting payment pursuant to
Government Code Section 13957.7(g)?
Location of Crime (If known)
SUSPECT
UNKNOWN
District AttorneyLaw Enforcement
CALIFORNIA VICTIM COMPENSATION PROGRAMSTATE OF CALIFORNIA FORM VCGCB-VCP-005 (Rev. 12/12) [ENG] Page 3 of 6
CA
CA
Caucasian Native American Other:
HEALTH INSURANCE COMPANY NAME:
POLICY NUMBER:
GROUP NUMBER:
TELEPHONE:
Ext.
STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY:
STATE:
ZIP:
FIRST NAME:
MIDDLE NAME:
LAST NAME:
Section 9 Insurance Informationt
Please list your insurance information below. The California Victim Compensation Program (CalVCP) is the payer of last
resort. We may contact your insurance company as a potential reimbursement source.
If you have no insurance of any kind, check here:
Name of Insured
Have you filed an insurance
claim related to this crime?
Section 8 Federal Reporting Information
The following voluntary information is for the person receiving compensation and is used for statistical purposes only to
comply with federal regulations.
Mailing Address
Ethnicity:
Is the victim disabled?
Was the victim disabled prior to the crime?
If you have more than one insurance provider,
please list on a separate piece of paper and mail with your application.
Health Insurance
Other:
Medi-Cal
Medicare Workers’ Comp
Please check any additional insurance sources that could be applied to your application:
Other Insurance
Asian, Pacific Islander African American Hispanic
Name of Insured
Have you filed an insurance
claim related to this crime?
Mailing Address
Auto/Vehicle Insurance (Includes car, truck, motorcycle, motorhome, boat, jet ski, airplane, etc.)
AUTO INSURANCE COMPANY NAME:
POLICY NUMBER:
TELEPHONE:
Ext.
STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY:
STATE: ZIP:
FIRST NAME:
MIDDLE NAME: LAST NAME:
CALIFORNIA VICTIM COMPENSATION PROGRAMSTATE OF CALIFORNIA FORM VCGCB-VCP-005 (Rev. 12/12) [ENG] Page 4 of 6
CA
CA
CALIFORNIA VICTIM COMPENSATION PROGRAMSTATE OF CALIFORNIA FORM VCGCB-VCP-005 (Rev. 12/12) [ENG] Page 5 of 6
FIRST NAME: MIDDLE NAME: LAST NAME:
TELEPHONE:
Ext.
Attorney’s Name
Mailing Address
STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY: STATE: ZIP:
Have you filed, or do you plan to file, a civil suit related to this crime?
Note: If you decide to file a civil suit, by law, you are required to notify CalVCP within 30 days of filing the action.
Civil Suit InformationSection 11
After entering all available information, print the application.
Attach copies of any documentation that supports your application for crime victim compensation, including copies of
crime-related bills, insurance, or anything relating to the crime. Save original documents for your records.
Please read the next page carefully, sign and date, and send to the address indicated or deliver to your local Victim
Witness Assistance Center.
CalVCP will send you a letter acknowledging that your application has been received. The acknowledgment letter will
include additional information about the benefits requested on your application.
A CalVCP representative may contact you for additional information if you were not able to provide it with your application.
For any questions about victim compensation, you can contact your local Victim Witness Assistance Center
or call CalVCP at 1-800-777-9229.
Your application for crime victim compensation is almost complete
EMPLOYER'S BUSINESS NAME:
FIRST NAME: LAST NAME:
TELEPHONE:
Ext.
STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY:
STATE:
Please list the victim's employer. If you are a parent/guardian seeking wage loss benefits because a minor victim was
hospitalized or is deceased, list your employer.
Contact Person
OK to contact
employer?
Did the victim miss work as a result of crime-related injuries?Is or was the victim self-employed?
Did the crime occur while the victim was on the job or at the workplace?
Is the victim disabled? / ¿La víctima está incapacitada?
NoYes / Sí
NoYes / Sí
Section 10 Employer Information
Mailing Address
ZIP:
►
►
►
►
►
►
If you have more than one employer, please list on
a separate piece of paper and mail with your application.
CA
CA
Signed:
Section 12 Information Release
Section 13 My Agreement to the California Victim Compensation Program
(Parent or guardian must sign if victim is a minor or incapacitated.)
(Parent or guardian must sign if victim is a minor or incapacitated. County social workers, see section 13a.)
Printed Name / Nombre Escrito:
This page MUST be signed and dated
As required by California law, I will contact and inform the California Victim Compensation Program (CalVCP) if I learn the claimant receives any payments from the offender, a civil lawsuit, an
insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt of benefits from CalVCP.
I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my knowledge and belief. I
understand that the claimant may be found to be ineligible for benefits, and that action may be taken to recover benefits the claimant receives if the claimant provides information that is false,
intentionally incomplete, or misleading.
Date:
Date:
Signed:
California Victim Compensation Program
PO Box 3036, Sacramento, CA 95812-3036
- or -
deliver to your local
Victim Witness Assistance Center
Mail completed application to:
1-800-777-9229
For more information call:
Hearing impaired, please call
the California Relay Service (711)
www.calvcp.ca.gov Helping California Crime Victims Since 1965
Printed Name:
I give permission to any healthcare provider; any medical biller, any funeral director or similar persons, any employer, any police or other government agency, including the Department of Justice,
the Social Security Administration, the State Franchise Tax Board, and the Federal Internal Revenue Service; any insurance company; or any other person or agency, to provide information
relating to this application, including medical (including, but not limited to history or physical records, consultation reports, pathology reports, discharge summaries, operative reports, X ray and
other radiology reports, laboratory reports, chart notes, narrative reports, and billing records), mental health, and felony conviction records, to the California Victim Compensation Program
(CalVCP) or its representatives, for the purpose of determining eligibility for CalVCP benefits. This permission also applies to all sources of recovery for the claimed losses, including but not
limited to, health or medical benefits, unemployment or disability benefits, Social Security benefits (Social Security disability, Supplemental Security income, and/or retirement, including the
supporting medical and/or mental health records), and Veteran benefits. I also give permission for the release of federal and state tax information, including tax returns, for the purpose of verifying
income. I hereby waive all legal privileges to any of this information required by CalVCP regarding my claim.
I agree that a photocopy or fax of this signed form is as valid as the original, and my signature gives permission for the release of all specified information.
I agree that CalVCP or its representatives may pursue restitution from the convicted offender in this matter to recover monies paid to me by CalVCP and that by filing this application I have
authorized use of information in this application and subsequent claim files to pursue restitution from the convicted offender.
In order to verify or process this application, I agree that CalVCP or its representatives may provide information about this application, and the information contained in this application, to any
representative named on this application, government agency, or health care provider or other provider of services, and may pay the provider directly if payment of these services is approved.
I agree that I may revoke this authorization at any time. The revocation must be in writing. The revocation will take effect when CalVCP receives it, but I may be deemed ineligible for CalVCP
benefits once the revocation is received by CalVCP. However, no healthcare provider may condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I
am entitled to a copy of this authorization except in limited circumstances. I agree that information disclosed under this authorization may be redisclosed by the recipient as required by law and
this redisclosure may no longer be protected by federal or state law.
I agree that the authorizations and agreements herein will expire ten (10) years after the date of my signing this form.
CALIFORNIA VICTIM COMPENSATION PROGRAMSTATE OF CALIFORNIA FORM VCGCB-VCP-005 (Rev. 12/12) [ENG] Page 6 of 6
As required by California law, I will contact and repay the California Victim Compensation Program (CalVCP) if I, or anyone on my behalf, receives any payments from the offender, a civil lawsuit,
an insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt of benefits from CalVCP, in the amount of the total
benefits granted by CalVCP. I understand I may be responsible for repaying CalVCP any amount for which it is later determined that I was not eligible. I will notify CalVCP if I hire an attorney to
represent me in any action related to this crime or if I pursue any action on my own.
Any monies I receive from CalVCP for moving/relocation expenses, improving home security, or for modifying a home or vehicle for a disabled victim will be used only for those purposes. If I am a
victim of domestic violence receiving moving/relocation expenses, I will not tell the offender my home address nor allow the offender on the premises at any time, or I will seek a restraining order
against the offender.
In the event that I am compensated for any pecuniary loss by CalVCP and the State of California subsequently receives compensation for the same loss on my behalf from the perpetrator
(including any monies received through a restitution order) or from any other source, I hereby assign to the Victim Compensation and Government Claims Board any and all rights to such
duplicate compensation.
I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my knowledge and belief. I
understand that I may be found to be ineligible for benefits, and that action may be taken to recover benefits I receive if I provide information that is false, intentionally incomplete, or misleading.
Section 13a For County Social Workers Only
Date:
Signed:
Printed Name / Nombre Escrito:
Printed Name:
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Application for Crime Victim Compensation Section 1 Claimant

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Completed 1 April 2022

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