CRIME DISCLOSURE
JD-VS-35 Rev. 12-18
C.G.S. § 54-209(d) and (e)
STATE OF CONNECTICUT
OFFICE OF VICTIM SERVICES
JUDICIAL BRANCH
www.jud.ct.gov/crimevictim/
Instructions
1. Print or type the information requested.
2. Please send to: Office of Victim Services, 225 Spring Street, 4th Floor, Wethersfield, CT, 06109
or Fax to: 860-263-2780 or e-mail to: OVSCompensation@jud.ct.gov.
Name of victim (first, middle, last)
Date of birth (mm/dd/yyyy)
1. Did the victim disclose that she or he was a victim of a crime in Connecticut?
6. Date of incident:
7. Check your profession:
To be eligible for victim compensation, victims must report the crime to police; however, state law allows victims of certain crimes to
disclose the crime to 1 of the professionals listed below instead of reporting to police. Victims of domestic violence may only disclose to
a certified sexual assault counselor or a certified domestic violence counselor instead of reporting to police.
Date incident disclosed to you:
No (skip to question 7)
alcohol and drug counselor
nurse (advanced practice, practical, or registered)
clinical social worker
physician or physician assistant
counselor
police officer
emergency medical services provider
psychologist
employee of Department of Children and Families
resident physician or intern at a Connecticut hospital
marriage and family therapist
sexual assault or domestic violence counselor (must be certified)mental health professional
surgeon
Name of the person completing form (print first, middle, last)
Provider license number, if applicable
Agency address, city, state zip
Name of agency
Telephone number
Title
Signature of person completing form
Date
Thank you for helping OVS in its efforts to provide financial compensation to eligible crime victims.
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, call OVS at 1-800-822-8428.
Name of claimant or person filing for claimant
Claim number Claims examiner
Yes (go to question 2)
school guidance counselor
school principal
school teacher
5. Describe the incident and any physical or emotional injuries:
2. Check the type of crime (you may check more than 1 box):
3. Did the victim suffer a physical injury?
sexual assault
human trafficking
domestic violence
child abuse
other:
Yes No
4. Did the victim suffer an emotional injury from a threat of either physical injury or death and received treatment?
Don't know
Don't knowNoYes
City/town of incident:
