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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA CRIME (Superior Court of DC)

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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
CRIME VICTIMS COMPENSATION PROGRAM
515 Fifth Street, N.W., Suite 109
Washington, D.C. 20001
APPLICATION FOR CRIME VICTIMS COMPENSATION
DATE RECEIVED: _______________________________
CLAIM NUMBER: _______________________________
INSTRUCTIONS
1. Please type or print clearly in ink.
2. If you need more space, attach additional sheets.
3. If you need assistance completing the form, call
(202) 879-4216 or come to the Crime Victims
Compensation Program at the address listed above.
4. Attach proof of crime (e.g. Law enforcement report,
Protection Order, SANE Receipt, Neglect Petition).
5. Attach all medical, hospital, and/or funeral bills and
submit them with your application. This will help the
processing of your application.
6. The Claimant must sign the application. If the
Claimant is under 18 years of age, the application must be
signed by the parent or guardian.
7. DO NOT INCLUDE costs for lost or damaged property or for
pain and suffering. They are not covered by D.C. Law.
8. If you do not know the answer to a question, please write
“unknown” in the space provided.
9. Please sign the Authorization for Release of Information.
10. Submitting information that you know is false, or withholding
important information is a crime and may result in a fine, and/or
imprisonment and forfeiture of compensation.
11. The total maximum that can be paid in a claim is $25,000. There
are sub-limits for certain expenses.
12. The crime MUST have occurred in the District of Columbia.
This is an application for:
Loss of Earnings Mental Health Services
Loss of Support Crime Scene Clean-up
Loss of Services Replacement Value of Clothing Kept as Evidence
Medical/Dental Expenses (No reimbursement when victim is deceased)
Funeral Expenses Temporary Emergency Housing or Moving Expenses for Victims in
Transportation to Receive Services Immediate Danger
Home Security Other: ____________________________________________
SECTION 1 – VICTIM/CLAIMANT INFORMATION (A separate application needs to be completed for each victim)
VICTIM'S NAME (The victim is the person injured as a result of a crime.)
Street Address (Mailing Address) City State Zip Code Ward
Home Telephone Number
Work Telephone Number
Date of Last Employment
Date of Birth
Social Security Number
Additional Means to Contact Victim/Cell Phone/Family Member /Email
CLAIMANT'S NAME (Person filing application for deceased, incapacitated or minor victim)
RELATIONSHIP TO VICTIM
Street Address (Mailing Address) City State Zip Code Ward
Home Telephone Number
Date of Birth
CV-2044B/May 2016 Page 1 of 7
*APPL*
SECTION 1 (continued) – VICTIM INFORMATION
NOTE: The following information concerning the victim is used for statistical purposes only.
Disabled:
Yes
No
Gender:
Male
Female
Not Reported
Primary Language:
English
Spanish
Other
_________________
(Please Specify
Race:
Asian
Black
White
Hispanic/Latino
Native American/Alaskan
Hawaii/Pacific Islander
Other Race
Multiple races
Not Reported
Who referred you to the compensation
program?
Law Enforcement Agency
U.S. Attorney’s Office
Department of Justice
Hospital
Media (TV, Radio, etc.)
Domestic Violence Intake Center
Other:______________________
(Please Specify)
SECTION 2 – CRIME INFORMATION
NOTE: If the crime did not occur in the District of Columbia, you must file a claim for compensation in the state where the crime occurred.
TYPE OF CRIME (please check one)
Arson Domestic Abuse Homicide
Assault Kidnapping Car jacking
Sexual Abuse Robbery Drunk Driving
Cruelty to Children Reckless Driving Stalking
Burglary Threats Other:_______________________
TYPE OF VICTIMIZATIONS
Is this crime related to:
Bullying
yes
no
unknown
Domestic/Family Violence
yes
no
unknown
Elder Abuse/Neglect
yes
no
unknown
Hate
yes
no
unknown
Mass Violence
yes
no
unknown
Date of Crime
Date Crime Reported
Agency to Which Crime Was Reported
Police Complaint Number
Officer’s Name
In cases of domestic abuse, please indicate Civil Protection Order number (if applicable)
In cases of sexual assault, medical treatment facility name (if applicable)
In cases of child cruelty, please indicate the neglect petition case number
Name of offender(s)
Did victim know offender(s)? YES NO, If YES, in what way?
____________________________________________________
Brief description of crime and
injuries;________________________________________________________________________________
Location of Crime (Street Address) City State Country
CV-2044B/May 2016 Page 2 of 7
SECTION 3 – MEDICAL/DENTAL/MENTAL HEALTH INFORMATION
*MENTAL HEALTH LIMIT: $3,000 for Adults and $6,000 for Minors
*MEDICAL AND DENTAL (in total) LIMIT: $25,000
Did you receive medical/dental/or mental health treatment? Yes No
Name of Physician, Hospital
or Other Provider of Service
Address
City/State/Zip
Phone Number
Amount of Bill
a.
b.
PLEASE SUBMIT COPIES OF ALL AVAILABLE BILLS RECEIVED TO DATE. PLEASE ATTACH ALL INSURANCE
PAYMENT STATEMENTS AND REJECTIONS.
SECTION 4 – FUNERAL EXPENSES
Limit: $6,000
Name of Funeral Home/Phone No: (Please attach a copy of the funeral bill)
Name of Cemetery/Phone No: (Please attach a copy of cemetery bill)
Total Amount of Funeral/Cemetery Bill: $ ________________Have the Funeral/Cemetery expenses been paid? YES NO
If YES, by whom? ________________________________________________________________________________________________
(Please submit receipt)
SECTION 5 – LOSS OF SUPPORT FOR SURVIVORS OF HOMICIDE
Limit: $2,500 per dependent, no more than $7,500 per claim
Have you submitted a claim to the Social Security Administration? YES NO
Did the victim have dependent(s)? YES (list dependents on section 8 of this application) NO
Did the victim provide support? YES (submit evidence of employment and/or child support) NO
SECTION 6 – LOSS OF SERVICES AND EXPENSES FOR SUBSTITUTE SERVICES
Limit: $250.00 per week, not to exceed $2,500
Please list all services such as child care and housekeeping that are no longer provided by the victim
as a direct result of the violent crime. Expenses Incurred
1. _____________________________________________________________ $ _______________
2. _____________________________________________________________ $ _______________
CV-2044B/May 2016 Page 3 of 7
SECTION 7 – LOSS OF WAGES
Limit: 80% of net pay, up to $10,000 or 1 year, whichever is reached first
Were you employed at the time of the crime? Yes No Date of last employment:__________________________
Victim’s Employer (at time of crime) _______________________________________________ _______________________________
Name Supervisor
___________________________________________________________________________________________________________________________________________________________________________________
_____
Street Address City State Zip Telephone Number
Gross Salary $ _______ per: hour day week month Hours Worked _____ per: day week
How long were you medically disabled and unable to work as a result of the crime/injuries?
From ____/ ____/ ____ Through ____/ ____/ ____ Did the crime occur at your job? Yes No
Mo. Day Yr. Mo. Day Yr.
Name of doctor who can verify length of disability to work: ______________________________________________.
(Please submit disability statement)
Did you receive pay from your job, when you were off from work? Yes No
______________________________________________________________________________________________________________
Doctor’s Name Street Address City State Zip Telephone Number
Self employed applicants for wage loss must attach a copy of their Federal Income Tax Returns for the preceeding 12 months.
EMERGENCY AWARD: Are you experiencing a financial hardship as a result of lost wages? You must have been employed at the
same time of the crime. YES NO NOTE: An emergency award is an advance of lost wages or reimbursement for
crime related expenses)
SECTION 8 – SECONDARY VICTIMS and DEPENDENTS
Submit copies of birth certificates for children. Please list the victims' dependents and household members and indicate whether they will
seek mental health counseling, because of this crime
Please complete the following information about dependents. (Dependent means a person wholly or partially dependent upon a victim for
care or support and includes a child of the victim born after the victim’s death.)
Name
Date of Birth
Address
Seeking Counseling
Due to the Crime?
Yes or No
Relationship to
Victim
1.
2.
3.
4.
CV-2044B/May 2016 Page 4of 7
SECTION 9 – INSURANCE AND OTHER COLLATERAL SOURCE INFORMATION
Awards may be decreased by the amount of funds available through collateral sources.
Source
YES
NO
Status of Application
Amount Paid
Health Insurance
Automobile Insurance
Workman’s Compensation
Medicare
Medicaid
Veteran’s Administration
TANF
Vacation/Annual/Sick/Pay
Food Stamps
Disability Benefits
Dental Insurance
Life Insurance
Burial Insurance
Unemployment Benefits
Social Security
Child and Family Services
Agency (Payment of
Counseling Expenses)
Section 8/HUD Housing
Other (specify)
SECTION 10 - RESTITUTION
If the court has ordered the offender to make restitution to you (pay you back), complete the following:
Date of Restitution Order Criminal Case #: __________________________
_____/ _____/ _____
Mo. Day Yr.
Amount
$
SECTION 11 – TEMPORARY HOUSING AND MOVING EXPENSES
Limit: $3,000 for temporary housing and $1,500 for moving expenses. A referral form may be requested.
Is this an award for temporary housing? YES NO
Moving Expenses? YES NO, If yes, please submit an approval letter, lease, and deed (private owners)
If YES, amount sought $ __________________
SECTION 12 – CLOTHING REPLACEMENT
Limit: $100. No reimbursement when victim is deceased.
Are any of the victim’s clothes being held by the police or prosecuting attorney as evidence: YES NO
If YES, what is the reasonable replacement value of the clothing? $ _______________
CV-2044B/May 2016 Page 5 of 7
SECTION 13 - TRANSPORTATION EXPENSES
Limit: $100 local travel and $500 necessary out of state travel.
Do you need assistance with the cost of transportation to receive treatment or services as a result of the crime? YES NO
SECTION 14 - REIMBURSEMENT FOR RENTAL OF A CAR BEING HELD AS EVIDENCE
Limit: $2,000
Note: The Crime Victims Compensation Program can only provide reimbursement, it cannot lease the vehicle for you.
Was your car held as evidence as a result of this crime? YES NO
Agency holding car as evidence: ________________________________________________________________
Name of Law Enforcement Officer ______________________________________ Phone: ________________
Car Rental Company: _______________________________________ (Please submit copy of lease agreement)
SECTION 15 – SECURITY MEASURES FOR THE HOME
Limit: $1,000
Are you seeking security measures for your home as a result of the crime? YES NO
Please submit estimates or receipts for services.
SECTION 16 – DECLARATION AND AFFIRMATION
SUBROGATION: If a monetary award is made, I agree to accept it under the provision of D.C. Code § 4-509. This law requires that any
money received from a civil suit relating to this crime, including settlement, be repaid to the Crime Victims Compensation Program up to
the amount awarded under this application.
If the District of Columbia desires, it can file suit against the offender for recovery. Should the District of Columbia decide to sue, it will
be responsible for all costs incurred and will recover those costs from monies awarded in the suit. I understand that I must fully cooperate
in any such suit instituted by the District of Columbia.
I HEREBY CERTIFY THAT I WILL NOTIFY THE DISTRICT OF COLUMBIA IN THE EVENT THAT I FILE SUIT
AGAINST THE OFFENDER OR THE COURT ORDERS THE OFFENDER TO MAKE RESTITUTION TO ME.
I DECLARE UNDER PENALTY OF FINE AND/OR IMPRISONMENT THAT THE INFORMATION CONTAINED IN THIS
APPLICATION FOR A CRIME VICTIMS COMPENSATION AWARD IS TRUE, CORRECT AND COMPLETE TO THE
BEST OF MY KNOWLEDGE.
___________________________________________________________ _______________
Signature of Victim/Claimant Date
___________________________________________________________ _______________
and/or Signature and Telephone number of Person Completing this Form Date
CV-2044B/May 2016 Page 6 of 7
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
CRIME VICTIMS COMPENSATION PROGRAM
515 Fifth Street, N.W., Suite 109
Washington, D.C. 20001
(202) 879-4216
(879) 879-4230 Fax
Name of Victim
Name of Claimant
Claim Number
(Official Use Only)
AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize and request any person having information necessary to the administration of my claim to release that information,
including all past law enforcement records concerning this claim, to the Superior Court of the District of Columbia Crime Victims
Compensation Program. This release includes, but is not limited to: private and governmental physicians, mental health service
providers, and hospitals; local, state and federal law enforcement agencies or prosecutors’ offices; revenue services and court
personnel; any employer, private company or governmental agency that is providing, or may provide, medical or monetary benefits.
The District of Columbia’s Department of Finance and Revenue is specifically authorized to provide the District of Columbia Crime
Victims Compensation Program with copies of my District of Columbia tax forms and withholding statements that may be required
to make final decision on this claim.
I agree and certify that no person shall incur any legal liability to me by releasing any information pursuant to this
authorization. A photocopy of the authorization is as effective and valid as the original.
__________________________________________ _____________________
CLAIMANT’S SIGNATURE DATE
CV-2044G/May 2016 Page 7 of 7
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Completed 13 August 2020

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