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Michigan Department of Health and Human Services (Michigan)

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DCH-0560 (Rev. 5-16) Previous edition may be used. 1 of 4
CRIME VICTIM COMPENSATION APPLICATION
Michigan Department of Health and Human Services
Claim Number
Cross Reference Number
For Office Use Only
AUTHORITY: PA 223 of 1976
COMPLETION: Is Voluntary, but is required if Crime Victim
Compensation is desired. Information on this form is exempt from disclosure
under the Freedom of Information Act.
The Michigan Department of Health and Human Services (MDHHS) does not
discriminate against any individual or group because of race, religion, age,
national origin, color, height, weight, marital status, genetic information, sex,
sexual orientation, gender identity or expression, political beliefs or disability.
INSTRUCTIONS
Please PRINT CLEARLY or TYPE all information in this application. Separate application must be completed for each victim.
• Enclose copies of crime-related itemized medical, dental, burial or counseling bills received to date if not fully paid by insurance
• Submit Explanation of Benefit for each date of service that was not paid in full by your insurance
• Submit 2 or 3 paystubs paid just before the date of injury, showing gross, net and tax deductions if applying for loss of wages
• Submit a written disability statement from your physician verifying dates you were unable to work
• For assistance in completing this application, call the victim only toll free number 877-251-7373 or 517-373-7373
• Return the completed application to the below address:
Crime Victim Services Commission
Grand Tower, Suite 1113
235 S. Grand Avenue
PO Box 30037
Lansing, MI 48909
Fax: 517-373-2439
SECTION 1 - Victim Information:
Complete this section for the person who was injured.
1. Name of VICTIM (Last, First, Middle)
3. Date of Birth
4. Social Security Number
2. Address (Number, Street, Apartment Number, etc.)
5. Home Telephone Number
6. Cell Phone Number
City
State
ZIP Code
7. Work Telephone Number
8. Marital Status
9. Gender
Single
Married
Separated
Divorced
Widowed
Male
Female
SECTION 2 – Claimant Information:
Please complete this section if the victim is a Minor Deceased Incapacitated
1. Name of CLAIMANT (Last, First, Middle)
3. Date of Birth
4. Social Security Number
2. Address (Number, Street, Apartment Number, etc.)
5. Home Telephone Number
6. Cell Phone Number
City
State
ZIP Code
7. Work Telephone Number
8. Marital Status
9. Gender
Married
Separated
Divorced
Male
Female
10. Your Relationship to the Victim
Spouse
Parent
Child
Sibling
Grandparent
Grandchild
Guardian
Other
11. Are you or were you dependent on the deceased victim for either
Primary Financial Support
NO YES
If yes, monthly amount
Child Support or Alimony
NO
YES
If yes, monthly amount
12. Dependents: Please list names and Birthdates of ALL Victim’s Legal Dependents
Names
Birthdates
Names
Birthdates
DCH-0560 (Rev. 5-16) Previous edition may be used. 2 of 4
SECTION 3 – Crime Information:
Complete this section and provide a copy of the Police Report if available.
1. Type of Crime (Check ONLY ONE)
Homicide
Assault
DWI/DUI
Vehicular Crime (other)
Robbery
Arson
Burglary
Sexual Assault
Child Abuse/Neglect
Child Sexual Assault
Child Pornography
Stalking
Human Trafficking
Terrorism
Fraud Financial Crimes
Kidnapping
Other (explain)
2. Was the person who caused the injury the victim’s spouse, former spouse, an individual with whom the victim had a child in common, or
a resident or former resident of the victim’s household?
YES
NO
3. Date of Crime
4. Date Crime was Reported
5. County which Crime Occurred
6. Police or Sheriff Agency to which crime was reported
7. Incident Number
8. Location of Crime (Number and Street)
City
State
Zip Code
9. Describe the Physical Injuries that resulted from this crime
10. Brief Description of Crime
11. If the crime was NOT reported to Police/Sheriff within 48 hours, please explain the reason for the delay
12. If you are NOT filing this claim within 1 year of the crime, please explain the reason for the delay
SECTION 4 – Restitution and Recovery Information:
Complete this section, providing all information you currently have available.
1. Name of Offender(s) if known
2. Has the Offender(s) been charged in court?
YES (If YES, complete questions 3 & 4) NO UNKNOWN
3. Name of Court
4. Court Case Number
5. Did the court order the offender to pay restitution to you?
YES (If YES, complete questions 6, 7 & 8) NO UNKNOWN
6. Restitution Order Date
7. Court Case Number
8. Amount Ordered
$
9. Have you filed, or do you intend to file a civil court action?
YES (If YES, complete questions 10, 11, 12 & 13) NO
10. Have you settled with a third party regarding this case?
YES NO UNKNOWN
11. Name of Attorney
12. Attorney’s Telephone Number
13. Attorney’s Address (Number, Street, Suite, etc.)
City
State
Zip Code
SECTION 5 – Statistical Information for Crime Victim Program:
For statistical purposes only. Completion of this section is strictly voluntary.
1. Please tell us how you first found out about the Crime Victim’s Compensation Program:
Prosecuting Attorney
Medical Provider
Attorney
Media, Brochure, or Poster
Police/Sheriff
Victim Service Agency
Friend/Acquaintance
Other
2. Race/Ethnic Background: Native Hawaiian or Other Pacific Islander
3. If Disabled, check one
White Non-Latino/Caucasian
Black-African American
Hispanic or Latino
BEFORE Crime
Asian Alaska Native
American Indian
Multi-Racial Other
As a RESULT of this crime
DCH-0560 (Rev. 5-16) Previous edition may be used. 3 of 4
SECTION 6 – Claim Determination Information:
1. Check the Type of Compensation Benefits you are requesting.
Medical Expense Benefits for the Victim
Funeral Benefits for the Survivor(s)
Loss of Earnings Benefits for the Victim
Loss of Support Benefits for the Survivor(s)
Counseling
Grief Counseling for homicide only
Crime Scene Clean-up for homicide only
2. Have you or will you suffer a minimum out-of-pocket loss of $200?
3. Have you lost at least 2 continuous weeks of earnings?
YES NO
YES NO
4. Is your injury the result of a Criminal Sexual Assault?
5. Are you Retired by reason of Age of Disability?
YES NO
YES NO
SECTION 7 – If you are applying for MEDICAL, DENTAL, COUNSELING:
Please complete this section, otherwise skip to Section 8. Please include all itemized medical bills, explanation of benefit and
receipts.
1. Please indicate which of the following sources (if any) are available to pay any medical bills or out-of-pocket expenses: (check ALL that
apply). Please attach any “Explanation of Benefit” statements that you have received to date.
Health Insurance
Dental/Vision Insurance
Veterans Administration
Medicaid
Medicare
Workers’ Compensation
State Medical Plan
None
Automobile Insurance
Homeowners Insurance
Other Public Assistance
Other (explain in #2)
2. Did the victim receive charity care, payments, donations, or other insurance settlement from any other source due to this incident:
YES If yes explain below: NO
3. Will Additional Medical Treatment be Required? (Please explain):
4. Name of Primary Medical Insurer:
SECTION 8 – If you are applying for FUNERAL EXPENSES, GRIEF COUNSELING, CRIME SCENE CLEAN UP, LOSS
OF SUPPORT: Please complete this section, otherwise skip to Section 9. Please include itemized bills.
1. Please indicate which of the following sources (if any) are available to pay any bills or out-of-pocket expenses: (check ALL that apply).
Please attach any “Explanation of Benefit” statements that you have received to date.
Life Insurance
Health Insurance
Social Security Death
Homeowners Insurance
State Emergency Relief
Workers' Compensation
Automobile Insurance
Other None
2. Did you receive donations or money from any source due to this incident?
YES If yes explain below: NO
SECTION 9 – If you are applying for LOSS OF EARNINGS:
If the victim was working, was disabled for 2 continuous weeks, and had taxable income, please complete this section,
otherwise skip to Section 10.
• Attach pay stubs showing gross, net and tax deductions for the victim’s earnings at the time of the crime.
• If at least 2 continuous weeks of work were missed, attach a doctor’s letter verifying this absence and the reason why.
•
If the victim is/was self-employed, attach copies of income tax returns for the year before the crime, and the year of the crime, if available.
1. Victim’s Employer Name
3. Supervisor’s Name
2. Employer’s Street Address
4. Supervisor’s Telephone Number
City
State
ZIP Code
5. Dates absent from work due to crime related injuries:
From:
To:
6. Name of Doctor who will verify Medical Disability
7. Doctor’s Telephone Number
8. Please indicate which of the following sources are available to pay for loss of earnings:
Long or Short term disability
Workers’ Compensation
Social Security
Other
None
SECTION 10 – Income Information:
Indicate YOUR HOUSEHOLD INCOME. If Parent or Guardian of a deceased, incapacitated, or minor victim, complete this
section showing the CLAIMANT’S Income.
1. Annual Household Income – We cannot accept zero
IMPORTANT:
Completion of this section is required for ALL Applicants.
We cannot accept zero
$
DCH-0560 (Rev. 5-16) Previous edition may be used. 4 of 4
AUTHORIZATION AND AGREEMENTS
Name of Victim:
Please print
Name of Claimant:
Please print
WARNING:
Falsely presenting facts and circumstances to this commission, with the intent to defraud or cheat,
may be a crime if compensation is awarded.
You DO NOT need an attorney to file a claim. If an attorney represents you in this claim, the attorney MUST file a
Letter of Appearance with this application.
YOUR SIGNATURE BELOW INDICATES YOUR UNDERSTANDING AND AGREEMENT TO THE FOLLOWING:
Authorization for Release of Information:
I authorize any hospital, doctor, counselor, or other treatment provider who attended
(Name of Victim); any funeral director or other person who rendered services; any employer; any police or other local
government agency, including State and Federal revenue services; any insurance company; or other organization having
knowledge; to furnish to the Michigan Crime Victim Services Commission, or its representative, all information concerning the
incident which led to the victim’s personal injury
or death, and the claim made for compensation, including treatment,
employment, insurance, or third-party payer information.
Repayment Requirement:
I understand that payment by the victim compensation program is payment of last resort. If I receive a payment from another
source for the same expenses, the State of Michigan is entitled to reimbursement up to the amount of any compensation
awarded to me through the Crime Victim Services Commission. I also understand that my providers may be paid directly for
debts that I owe.
Financial Hardship:
I understand that my eligibility for crime victim’s compensation required that losses represent a serious financial hardship for
me. I attest that there are no other financial resources or income available to me. I attest that un-reimbursed losses claimed
in this application will cause me serious financial hardship.
Declaration:
I declare, under penalty of perjury, information on this form is true, correct, and complete to the best of my knowledge and
belief.
Claimant’s Signature Date of Signature
Note: A photocopy of this a
uthorization is as effective
and valid as the original.
Please keep a copy of all documentation for your records.
RETURN COMPLETED, SIGNED APPLICATION AND SUPPORTING DOCUMENTATION TO:
Crime Victim Services Commission
Grand Tower, Suite 1113
235 S. Grand Avenue, PO Box 30037
Lansing, MI 48909
Fax: 517-373-2439
For Assistance Call: Victim only toll-free: 877-251-7373
All others: 517-373-7373
Page 1 of 2
STATE OF MICHIGAN
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CRIME VICTIM SERVICES COMMISSION
Phone: (517) 373-7373 • Fax: (517) 373-2439 • Victims Only Line: (877) 251-7373
Mailing Address: Crime Victim Services, Grand Tower Suite 1113, 235 South Grand Avenue, PO Box 30037, Lansing MI 48909
COMPENSATION CHECKLIST
Use The Checklist Below For The Specific Compensation You Are Requesting
Please be advised that additional information may be necessary at a later date in the application process
Processing of an application may take 12 to 16 weeks
Please make sure that you have answered all sections of the application
MAKE SURE REQUIRED DOCUMENTS ARE INCLUDED WITH YOUR APPLICATION
For All Applications:
_____ Make sure your household income is entered on the application in the appropriate section- It can NOT be
blank or “0”- Show your source of support
_____ Submit a copy of the police report if you have it
_____ IF THE DATE OF CRIME HAS BEEN OVER 1 YEAR, A COPY OF THE POLICE REPORT
IS REQUIRED TO BE SENT IN WITH THE APPLICATION along with written explanation as to why
you didn’t apply within a year from the date of the crime
_____ Submit a copy of the Case Action Notice verifying eligibility from the Department of Health and
Human Services if they assisted you after the crime
_____ ___________________________________________________________________________________
Applying for Medical Bills and/or Counseling?:
_____ Submit Itemized copies of all medical/counseling bills, plus copies of any paid receipts AND……
_____ All medical/counseling bills should be submitted to your insurance, Medicaid, or Medicare carrier first;
then provide copies of the Explanation of Benefits (or Case Action Notice if you have Medicaid)
showing rejection of coverage or partial payment
_____ If you have injuries that require medication or replacement of medical equipment such as glasses,
dentures, etc.; send a copy of the prescription, the itemized bill or itemized estimate, and copy of the
receipt if you have already paid
_____ If you are applying for a medical procedure that has not taken place yet, and you need a pre-
authorization, please provide a written itemized estimate from the provider for the procedure
_____ If you are permanently disabled because of your injury, send a copy of the prescription and two cost
estimates for any necessary rehabilitative equipment or modifications of your home or vehicle
_____ If you are applying for counseling, submit a copy of the initial assessment and goal oriented treatment
plan from your counselor or therapist
Continued On Page 2…
(09/27/2016)
Page 2 of 2
COMPENSATION CHECKLIST Continued…
Applying for Burial Benefits?:
_____ Submit an Itemized copy of the funeral bill, including cemetery and funeral home bills, plus copies of
any paid receipts
_____ If somebody other than you made a payment toward the funeral costs, and they allow you to be
reimbursed for their payment; provide a notarized statement from that person authorizing you to be
reimbursed for that payment
_____ Submit the Life Insurance Benefit Statement
Applying for Loss of Earnings or Support?:
_____ If you are applying for loss of earnings and are NOT self-employed, provide copies of 2 or 3 pay stubs
paid just before the date of injury
_____ If you are applying for loss of earnings and ARE self-employed, provide a copy of the most recent
Federal and State Income Tax Return including Schedule C
_____ If you are applying for loss of earnings, submit a written disability statement from your physician
verifying your physical disability and specific dates off work
_____ If you are applying for loss of support, provide a copy of the Life Insurance Benefit Statement and/or
Social Security Survivor’s Benefit Statement for you and your children
_____ If you are applying for loss of support, please provide a copy of the court order for child support
_____ If you are applying for loss of support, please provide a copy of the victim’s most recent Federal and
State Income Tax Returns and W-2 forms
(09/27/2016)
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Completed 7 October 2021

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