Fillable BUREAU OF VICTIM COMPENSATION CLAIM FORM OFFICE OF (Florida Attorney General)

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BUREAU OF VICTIM COMPENSATION CLAIM FORM OFFICE OF (Florida Attorney General)

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IS THE VICTIM (check one)
DECEASED INJURED MINOR
MINOR WITNESS -
INCOMPETENT
NOT INJURED
APPLICANT NAME DATE OF
(last, rst, middle) BIRTH
SOCIAL E-MAIL WOULD YOU LIKE ALL CORRESPONDENCE
SECURITY NO. ADDRESS SENT BY EMAIL?
YES NO
ADDRESS CITY STATE ZIP
CODE
TELEPHONE ALTERNATE RELATIONSHIP OCCUPATION
NUMBER
PHONE NUMBER
TO VICTIM
VICTIM’S NAME DATE OF
(last, rst, middle) BIRTH
SOCIAL E-MAIL WOULD YOU LIKE ALL CORRESPONDENCE
SECURITY NO. ADDRESS SENT BY EMAIL?
YES NO
ADDRESS CITY STATE ZIP
CODE
TELEPHONE ALTERNATE OCCUPATION
NUMBER PHONE NUMBER
THIS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL. NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER OTHER RACE
RACE/ETHNICITY: AMERICAN INDIAN/ ASIAN BLACK/AFRICAN HISPANIC or
ALASKA NATIVE AMERICAN LATINO WHITE NON-LATINO/CAUCASIAN MULTIPLE RACES
GENDER: Male Female NATIONAL ORIGIN WAS VICTIM DISABLED
BEFORE THE CRIME OCCURRED?
YES NO
Instructions
Please read the Eligibility Requirements to see if you qualify for this program. Fill out this form completely (please print), attach all required
documentation, and submit to the above address. If you change your mailing address, phone numbers, or email, you are required to notify this oce.
CHECK THE TYPE OF VICTIM COMPENSATION BENEFITS YOU ARE REQUESTING:
DISABILITY -
compensation for the victim who suffered a permanent disability.
(Attach documentation as outlined in Section 3.)
WAGE LOSS - compensation for the victim who lost wages due to crime related
physical injuries. (Attach documentation as outlined in Section 3.)
LOSS OF SUPPORT - compensation for the dependent(s) of a deceased victim
who was employed at the time of the crime. (Attach documentation as outlined in
Section 4.)
EXPENSES - payment or reimbursement for funeral/burial, medical, dental, mental
health, and/or grief counseling treatment expenses directly related to the crime. (Attach
itemized bills and receipts for selected expenses.)
FUNERAL/BURIAL MEDICAL* MENTAL HEALTH
GRIEF COUNSELING** DENTAL
EMERGENCY ASSISTANCE - reimbursement for documented wage loss and
out-of-pocket expenses related to the crime. (Attach receipts.)
PROPERTY LOSS - for the victim over the age of 60 or disabled adult who
suffered the loss of tangible personal property as the result of a criminal or
delinquent act. Attach proof of disability prior to the date of crime from the
Department of Veteran Affairs, Social Security Administration, or a Property Loss
Disability Verication Form (BVC410), and a receipt or written estimate from a
vendor or merchant identifying the comparable replacement value. Compensable
items must be identied by the law enforcement report.
SEXUAL BATTERY RELOCATION ASSISTANCE - for the victim of sexual battery
seeking assistance to relocate due to a reasonable fear for his or her safety. A
completed Relocation Certication Worksheet (BVC106) from a certied rape crisis
center must be received.
DOMESTIC VIOLENCE RELOCATION ASSISTANCE - for the victim of
domestic violence seeking assistance to relocate to a safe environment.
A completed Relocation Certication Worksheet (BVC106) from a certied
domestic violence center must be received within 30 days from the date of crime.
HUMAN TRAFFICKING RELOCATION ASSISTANCE - for the victim of sexual
trafcking with an urgent need to relocate. A completed Relocation Certication
Worksheet (BVC106) from a certied rape crisis or domestic violence center
must be received within 45 days of the crime or last identiable threat.
Section 1. Victim and Applicant Information
The applicant ling on behalf of a victim is required to provide claimant information below. When requesting compensation on behalf of an incompetent adult victim, proof
of legal guardianship must be attached, and the applicant’s signature on the claim form must be witnessed by a Notary Public.
CHECK ALL OTHER TYPES OF BENEFITS YOU ARE REQUESTING: (Separate claim numbers will be assigned.)
( ) ( )
( ) ( )
The Ofce of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.
BVC100 (03/21)
Page 1 of 4
OFFICE OF THE ATTORNEY GENERAL
BUREAU OF VICTIM COMPENSATION CLAIM FORM
PL-01, The Capitol, Tallahassee, FL 32399-1050
•
Information and Referral: (800) 226-6667
•
Fax: (850) 414-6197
Bill Status Information for Providers: (850) 414-3331
•
Hearing Impaired Users May Call Through Florida Relay: (800) 955-8771
Website: MyFloridaLegal.com
•
Web Portal: https://VANext.MyFloridaLegal.com
•
Email: VCIntake@MyFloridaLegal.com
*Includes prescriptions, eyeglasses, dentures and prosthetic devices **For individuals whose relationship with the deceased is a spouse, parent, child, sibling or dependent
FL
FL
Section 2. Referral Source Information
Individuals who assisted with or lled out any sections of this application are required to provide referral information below. By signing this application, the victim/applicant
afrms that all information provided is true and correct, and thus, all sections should be reviewed before the application is signed. (Treatment providers can request training
on the Victim Compensation Program, which is recommended prior to becoming a referral source.)
NAME OF PERSON ASSISTING WITH APPLICATION E-MAIL
(last, rst, middle) ADDRESS
NAME OF AGENCY/ORGANIZATION
AGENCY/ORGANIZATION’S ADDRESS TELEPHONE
(address, city, state, zip code) NUMBER
Section 3. Disability or Lost Wages Information
When requesting compensation for wage loss, attach a completed Victim Compensation Wage Loss Employment Report (BVC405), or if you are self-employed or work for
a family member, attach a copy of your latest led income tax return and applicable IRS schedule forms. If more than 40 hours of work were missed, attach a completed
Victim Compensation Treatment Disability Statement (BVC409). When requesting permanent disability compensation, attach a completed Victim Compensation Treatment
Disability Statement (BVC409).
SUPERVISOR’S NAME TELEPHONE
NUMBER
NAME OF COMPANY/BUSINESS
(if more than one [1] employer, please attach additional sheet)
COMPANY ADDRESS
(address, city, state, zip code)
IS WAGE LOSS COVERED BY INSURANCE? YES NO IS VICTIM DISABLED AS A RESULT OF THE CRIME? YES NO
IS WAGE LOSS COVERED BY WORKER’S COMPENSATION? YES NO
Section 4. Loss of Support and/or Grief Counseling Information
Indicate the name(s), date(s) of birth, and relationship to the deceased victim for any surviving spouse, parent, child, sibling, or dependent. For persons under the age of 18,
also indicate who has guardianship of the minor. Attach income tax returns showing earnings for one to three years preceding the date of the crime, or alternatively a Victim
Compensation Wage Loss Employment Report (BVC405) to document earnings preceding the crime. Also attach proof of dependency established based upon the victim’s
federal income tax return, marriage certicate, birth or death certicate, copy of approval for Social Security Administration survivor benets, or court order for support.
DEPENDENT/MINOR CLAIMANT NAME(S) DATE OF BIRTH RELATIONSHIP TO VICTIM
Section 5. Insurance Information
Victims who are determined eligible for the Victim Compensation and Property Loss Programs may be exempt from the insurance deductible or co-payment provisions of their
insurance policy(ies).
IS INSURANCE OR MEDICAID AVAILABLE TO ASSIST WITH THESE EXPENSES? YES NO MEDICAID NUMBER:
If yes, provide the following for all insurance policies, including Medicaid, Medicare, life, homeowner’s, automobile, or major medical. Attach all related insurance Explanation of Benets statement(s).
1. COMPANY NAME POLICY NUMBER TELEPHONE
NUMBER
ADDRESS CITY STATE ZIP
CODE
2. COMPANY NAME POLICY NUMBER TELEPHONE
NUMBER
ADDRESS CITY STATE ZIP
CODE
Section 6. Other Compensation, Settlement, and Attorney Information
You must notify this ofce if you have received, or if you anticipate receiving compensation or any benets from any other source as a result of this incident. You must also
notify this ofce if you have or are planning to hire an attorney to represent you as a result of the incident.
STATE THE SOURCE AND ARE YOU REPRESENTED ATTORNEY’S NAME
DATE RECEIVED (IF APPLICABLE) BY LEGAL COUNSEL? YES NO
ADDRESS E-MAIL
ADDRESS
CITY STATE ZIP TELEPHONE
CODE NUMBER
( )
( )
( )
( )
( )
The Ofce of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.
BVC100 (03/21)
Page 2 of 4
FL
FL
FL
Section 7. Crime Information
This section must be completed and proof of crime (such as a law enforcement report or charging afdavit) must be attached. Failure to submit proof of crime will result in
your application not being processed or your claim being denied.
NAME OF LAW DATE OF DATE REPORTED TO LAW
ENFORCEMENT AGENCY CRIME ENFORCEMENT AGENCY
WAS THE CRIME REPORTED TO LAW ENFORCEMENT WITHIN 120 HOURS? YES NO
If no, please explain. (If no, failure to provide an acceptable explanation in this section will result in a denial of benets.)
IS THE APPLICATION AND ACCEPTABLE DOCUMENTATION PROVING A COMPENSABLE CRIME OCCURRED BEING SUBMITTED WITHIN THREE YEARS FROM THE DATE OF CRIME?
YES NO If no, please explain. (Please be advised that most benets apply to treatment losses suffered within one year from the date of crime, with some exceptions for minor
victims. If no, failure to provide an acceptable explanation in this section will result in a denial of benets.)
TYPE OF CRIME AS SPECIFIED LAW ENFORCEMENT
ON THE LAW ENFORCEMENT REPORT REPORT NUMBER
NAME OF LAW NAME OF OFFENDER
ENFORCEMENT OFFICER (if known)
NAME OF ASSISTANT STATE ATTORNEY STATE ATTORNEY/
HANDLING THE CASE (if applicable) CLERK OF COURT CASE NUMBER (if applicable)
Victim Compensation (VC): The victim must have suffered a physical injury or death as the result of a compensable crime; a psychiatric or psychological injury as a result of a
forcible felony; or a mental injury as a result of child abuse as diagnosed by a psychologist or physician.
Property Loss (PL): The victim must have suffered a substantial diminution in their quality of life from the loss of tangible personal property as the result of a criminal or delinquent
act. Property loss benets cannot exceed the maximum payment amount determined by the Schedule of Benets on any one claim, and a lifetime maximum of $1,000 on all claims.
Domestic Violence Relocation Assistance (DV): The victim must need immediate assistance to escape a domestic violence environment. The Relocation Certication Worksheet
(BVC106) certied by a domestic violence center in the State of Florida is required and must be received within 30 days after the domestic violence crime occurred.
Relocation for Victims of Sexual Battery (RS): The victim must need to relocate due to a reasonable fear for his or her safety. The Relocation Certication Worksheet (BVC106)
certied by a rape crisis center in the State of Florida is required and must be received within three years after the sexual battery crime occurred.
Human Trafcking Relocation Assistance (HT): The victim must have an urgent need to escape from an unsafe environment directly related to a sexual human trafcking offense.
The Certication Worksheet (BVC106) certied by a domestic violence or rape crisis center in the State of Florida is required and must be received within 45 days of the crime or last
identiable threat communicated with the proper authorities.
Basic Eligibility Requirements: The victim must cooperate fully with law enforcement ofcials, State Attorney’s Ofce, and the Attorney General’s Ofce. The crime must be reported
to the proper authority within 120 hours, unless there is good cause for delayed reporting. Applications must be received within three years, or within ve years with good cause after
the crime, the crime related death of the victim or intervenor, or after the date the death of the victim or intervenor is determined to be the result of a crime. Exceptions for ling time
requirements apply to victims who are minors. The victim must not have engaged in an unlawful activity or contributed to the situation that brought about his or her own injury or death.
Criminal History Record Check: In order for compensation to be considered, the victim, and if applicable the applicant, must not have been conned or in custody in a county or
municipal facility; a state or federal correctional facility; or a juvenile detention commitment, or assessment facility; adjudicated as a habitual felony offender, habitual violent offender,
or violent career criminal; or adjudicated guilty of a forcible felony offense.
Notice of Payment Limitations: The Bureau of Victim Compensation may provide nancial assistance to or on behalf of qualied crime victims, but only after all other sources of
payment have been exhausted. Payments accepted by in-state providers on behalf of victims are considered payment-in-full per Florida Statute. Total victim compensation benets
cannot exceed the maximum payment amount determined by the Schedule of Benets. Limits below the maximum may apply and can be reduced without prior notice to the award
recipient based on the availability of funding.
Relocation Payment Limitations: A standard housing contract or a Notication of Residential Agreement (BVC110) is required at the time of application. Only short-term interim
shelter, rental agreements, or long-term leases for a new location qualify. A victim whose relocation claim is determined eligible and payment is made must accept funds at the
certifying domestic violence or rape crisis center within 30 days of payment issuance, and are required to submit and the department receive itemized documentation within 45 days
from payment issuance, proving funds were used to satisfy the housing contract or agreement. Total relocation benets cannot exceed the maximum payment amount determined by
the Schedule of Benets on any one claim and a lifetime maximum of $3,000 on all claims for that benet type.
Acceptable Proof of Crime: The Bureau of Victim Compensation does not make an independent judgment on whether a compensable crime occurred, but instead relies on proof
of crime from the proper authorities. Failure to provide acceptable documentation proving that a compensable crime occurred shall result in your application not being processed
or your claim being denied. Acceptable documentation for proof that a compensable crime occurred shall include a law enforcement report; afdavit charging an individual with
a crime led by law enforcement; information charging an individual with a crime led by a state attorney; indictment by a grand jury; written communication from any federal law
enforcement agency; cybercrime investigator certication for purposes of s. 960.197, Fla. Stat.; or Law Enforcement Information Reporting Form (BVC430).
Complete Application Package: It is your responsibility to provide a complete application package which includes acceptable documentation proving that a crime occurred. If
the department receives a report which is insufcient for proving that a compensable crime occurred, the application will be assigned a claim number and denied. Claim numbers
assigned are not indicative of eligibility or denial. For assistance with collecting acceptable documentation, please contact your local law enforcement agency, the agency where the
crime was reported, the referral source, or your local State Attorney’s Ofce.
Section 8. Eligibility Requirements
Additional qualication criteria, deadlines, and exceptions not listed may apply.
The Ofce of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.
BVC100 (03/21)
Page 3 of 4
VICTIM: Must be signed and dated by the victim if ling as a competent adult.
Printed Name:
Signature: Date:
Under penalty of perjury or fraud, the information I have provided is true and correct to the best of my knowledge.
APPLICANT: Applicant signature is required if ling as the parent, legal guardian, or individual authorized to administer a victim’s estate.
Printed Name:
Signature: Date:
Under penalty of perjury or fraud, the information I have provided is true and correct to the best of my knowledge.
NOTARIZATION REQUIREMENT: Persons submitting an application on behalf of an incompetent adult must submit proof of legal guardianship
and have their signature witnessed by a Notary Public.
Sworn to and subscribed before me this day of , 20 .
Personally known to me. Identication produced.
Notary Public Signature: Stamp/Seal:
PLEASE READ CAREFULLY AND SIGN THE FOLLOWING CERTIFICATIONS
Section 9.
CONFIDENTIALITY: If you are the victim of a sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, you have the right
to have information about your home address and telephone number, employment address and telephone number, and your personal assets, kept condential for a period of ve
years. If you are the victim of any of these crimes, please mark one of the following statements. Your response will not affect the processing of your claim.
I want the information to be condential I do NOT want the information to be condential
SERIOUS FINANCIAL HARDSHIP: I certify that I have a serious nancial hardship because of crime-related expenses that cannot be paid by any other source.
PROPERTY LOSS CERTIFICATION: I certify that the property in question belonged to the victim; that this loss adversely affects the victim’s quality of life; that there is no other
source of reimbursement for this loss; and that replacement of the property would cause the victim a serious nancial hardship.
RELEASE OF INFORMATION: I give permission to any hospital, doctor, dentist, mental health counselor, or other treatment provider, banking institution, social service agency, law
enforcement agency, corrections agency, state attorney’s ofce, insurance carrier, attorney or employer to provide information that is requested concerning any treatment rendered,
employment, insurance, third-party payer, or law enforcement investigative information to the Bureau of Victim Compensation for use in processing my claim. I give permission to the
Bureau to release information about the status of my claim to any treatment provider, law enforcement agency, or state attorney’s ofce.
SOCIAL SECURITY NUMBER DISCLOSURE: The Bureau of Victim Compensation collects and uses Social Security numbers for the purpose of performing imperative duties and
responsibilities which may include the following: searching criminal history records, identity management, billing and payments, benet processing, and reporting to authorized state and
federal government agencies. Failure to provide this optional information may delay the processing of your application or benets. Federal and State laws require the Bureau to protect
Social Security numbers from disclosure to unauthorized parties. Absent a waiver from you or your legal representative, Social Security numbers will be redacted, unless the agency
receives a court order to turn over a non redacted le.
REPAYMENT REQUIREMENT: I understand that I must notify the Bureau of Victim Compensation before a civil settlement, restitution order, and/or any proceeds are obtained by
any source. I acknowledge that the Bureau of Victim Compensation is the payor of last resort and that I must repay the Crimes Compensation Trust Fund if I receive compensation
and also receive payment from another source as a result of the same criminal incident. Other sources include, but are not limited to, any payment from the offender, insurance
policy, settlement, agreement, judgment, or an award in a third-party lawsuit. I also understand that if eligibility is rescinded or withdrawn, I must repay any amount received or paid
on my behalf by the Crimes Compensation Trust Fund.
The Ofce of the Attorney General, Bureau of Victim Compensation is an equal opportunity provider and employer.
BVC100 (03/21)
Page 4 of 4
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Completed 8 July 2022

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