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TENNESSEE CRIMINAL INJURIES COMPENSATION APPLICATION (State of Tennessee)

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TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
State of Tennessee
Division of Claims and Risk Management
502 Deaderick Street w Nashville, Tennessee 37243-0202
Telephone: (615) 741-2734 w Fax: (615) 532-4979
Webs
ite: www.treasury.tn.gov/injury
E-mail: Criminal.Injury@tn.gov
A Division of the Tennessee Treasury Department
TENNESSEE CRIMINAL INJURIES COMPENSATION APPLICATION
PURPOSE
When a person is injured in a crime in the state of Tennessee, that vicm or certain family members may apply to the
Tennessee Criminal Injuries Compensation Program for help with the injury-related expenses. The program is managed by
the Tennessee Treasury Department’s Division of Claims and Risk Management. The goal of the program is to ease the
financial burden of crimes involving injury whenever the victim or family members meet certain requirements. The program
can approve a claim only if the victim meets eligibility requirements, if the crime involves injury and is a type of crime the
program can consider, and if the expenses covered by the program are properly documented.
A
PPLICATION INSTRUC
TIONS
;
File an applicaon within one year of the date of injury or death. If the vicm is under 18 years of age, the legal guardian
must le the claim on behalf of the minor vicm. The guardian may le the claim unl the vicm reaches 18 years of age.
An adult who was vicmized as a minor, or who lost nancial support as a minor due to the death of a vicm, may le on
his/her behalf unl he/she reaches age 19.
; Complete all pages of the applicaon. If compleng by hand, use BLACK or BLUE INK. Please print clearly. Answer all
quesons. Unanswered quesons will slow or prevent the processing of the applicaon. The person ling the claim must
sign Secon G in the presence of a notary.
; You are not required to have an aorney complete this applicaon. If you wish, however, you may do so. Any
communicaon about your claim will be directly through your aorney, and he/she may be eligible for aorney fees.
; Submit the applicaon to the program oce at the address on the top of this page. The applicaon is not “led” unl the
Division of Claims and Risk Management receives all completed pages by mail or by fax. Call (615) 741-2734 and ask to
speak to a Customer Service Representative if you have questions about the application.
; The expenses you want the program to consider must be rst led with any/all other public or private sources of
assistance, such as health, life, burial, and/or auto insurance, workers’ compensaon, sick leave/vacaon pay, etc. The
program can only consider those expenses the vicm or relave must pay out of pocket. This is a fund of last resort.
; Aach copies of itemized bills from service providers, receipts, insurance benet statements, and any other
documentaon to support the expenses you wish the program to consider. Refer to the list of eligible expenses on the rst
page of the applicaon if you are not sure the expense can be considered.
; Respond as soon as possible to any leers from our oce.
; Nofy our oce immediately if there is any change in your address or phone number while the claim is being processed.
The claim may be denied if we have no valid contact informaon.
e Tennessee Department of Treasury operates all programs and activities free from discrimination on the basis of sex, race, or
any other classication protected by federal or Tennessee state laws. Individuals with disabilities who may require an alternative
communication format for this or other Treasury Department publications should contact Treasury Department Human Resources
at 615-253-8769. Any person who believes she or he has been discriminated against in Treasury Department programs should write
to: Title VI Coordinator, Treasury Department Human Resources, Andrew Jackson Building, 13th Floor, Nashville, Tennessee 37243.
VERIFICATION OF APPLICATION: I hereby cerfy, subject to the penalty of ne and imprisonment, that the informaon contained in
this applicaon for criminal injuries compensaon is true and correct to the best of my knowledge.
SUBROGATION: In consideraon of the payment received from the Criminal Injuries Compensaon Fund, I agree to repay the Fund
the full amount I (or my child or ward) received from the Fund in the event I (or my child or ward) recover damages or compensaon
from the oender or from any other public or private source as a result of the injuries or death which was the basis of my claim for
compensaon from the Fund. For purposes of this Agreement, I understand that compensaon from “any other public or private
source” includes, but is not limited to, receipt of insurance, Medicare, Medicaid, TennCare, workers’ compensaon, disability pay,
etc. I further agree and understand that no part of the recovery due the Criminal Injuries Compensaon Fund may be diminished by
any collecon fees or for any other reason whatsoever. Should I (or my child or ward) choose to recover damages or compensaon
for the injury or death from any source, I agree to promptly nofy the District Aorney General in the district where the crime
occurred and the Criminal Injuries Compensaon Program by sending to the District Aorney General and the Compensaon
Program copies of any pleadings, selement proposals and any other documents relave thereto. I further agree to fully cooperate
with the State of Tennessee should the State instute an acon against any person or enty for the recovery of all or any part of the
compensaon I (or my child or ward) received from the Fund.
RELEASE OF INFORMATION AUTHORIZATION: I hereby authorize any hospital, physician, funeral director, municipal authority,
employer or union, insurance company, social service bureau, Social Security oce, or any other person, rm, agency, or organizaon
to furnish to the Tennessee Criminal Injuries Compensaon Fund, or its representave, any informaon requested, including tax data
and prior police records, needed to perfect my claim for compensaon. A photocopy of this authorizaon shall be considered as
eecve and valid as the original.
PUBLIC RECORDS: Except as otherwise provided by applicable federal or state law, the informaon contained in this applicaon
and all documents submied in support of your claim are subject to the Public Records Laws of the State of Tennessee pursuant to
Tennessee Code Annotated, Title 10, Chapter 7, Part 5.
I cerfy that I have read and/or understand and agree to the above statements.
Vicm/Claimant’s Signature: _________________________________________ Date: _______________________________
Vicm/Claimant’s Printed Name: ______________________________________
State of ______________ / County of ___________________
Sworn to and subscribed before me, the undersigned Notary, on this, the ________ day of ______________________, 20 ________ .
(SEAL) Notary’s Signature: __________________________________
My Commission Expires: _____________________________
SECTION G - AUTHORIZATION AND SUBROGATION
SECTION H - ATTORNEY INFORMATION
Page 4 of 5
SECTION E - INSURANCE AND FINANCIAL ASSISTANCE
Is there any benet program, employer benet, or insurance coverage to assist with the expenses being claimed?
* No * Yes
If yes, please check below the benets that have been paid (or may be paid), in part or in full, for any expenses you are
claiming. Also, provide documentaon of payments made.
* Automobile Insurance * Homeowner’s Insurance * Social Security (death benets, disability, etc.)
* Burial Insurance * Life Insurance * Vacaon/Annual Pay
* Disability * Medicare/Medicaid/TennCare * Veterans Administraon/Insurance
* Donaons * Oender/Court-Ordered Restuon * Workers’ Compensaon
* Health Insurance * Sick Pay * Other (specify) ________________________
Has the court ordered the oender to pay you for your nancial losses?
* No * Yes
If yes, please aach a copy of the order of restuon.
Have you led or do you plan to le a lawsuit for your injuries?
* No * Yes * Unknown
If yes, and you are represented by an aorney, please provide the aorney’s name and telephone number.
___________________________________________________________________________________________________
Page 5 of 5
Please describe what happened and the injuries suered as a result. Aach a copy of the police report.
Also, please aach a copy of the death cercate if the vicm is deceased.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Name and address of oender(s), if known. (By law, we are required to nofy oender(s) of this claim.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Did the vicm know the oender(s)?
* No * Yes If yes, in what way? ______________________________________
Was the vicm living in the same house with the oender at the me of the crime?
* No * Yes
Does the vicm sll live with the oender?
* No * Yes
Who is handling the criminal case?
* State Prosecutor * Federal Prosecutor
SECTION D - CRIME INFORMATION continued
SECTION F - LOST WAGES
Complete this secon only if you are the vicm named in Secon B and you are claiming lost wages from your job at the me
of injury. Informaon needed to verify lost wages is described below. DO NOT complete this secon if the vicm is deceased.
Did you, the vicm, miss work due to injuries?
* No * Yes
If yes, please have your employer(s) complete an Employer’s Statement form. If you missed more than two weeks of work,
please provide a doctor’s statement or a doctor’s release to return to work.
Were you self-employed at the me of the crime?
* No * Yes
If yes, submit the most recent income tax return or statements from those for whom the vicm worked, showing
amount(s) paid and date(s) for a period of at least 12 months prior to the crime. If you missed more than two weeks of
work, please provide a doctor’s statement or a doctor’s release to return to work.
If you choose an aorney to complete the applicaon for you, the aorney must complete and sign this secon. NOTE: This is not
the state or federal prosecutor handling the criminal case.
Aorney’s Full Name: _________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
(Street) (City) (County) (State) (Zip Code)
Phone Number: _____________________________________ FEIN or SSN: ___ ___ ___ ___ ___ ___ ___ ___ ___
 - I hereby cerfy that I have been retained by and represent the vicm and/or claimant ling this applicaon.
I further cerfy that I have read through this enre applicaon with such person and that such person indicated that he/she
understood every queson and provision contained herein.
Aorney’s Signature/Date: __________________________________________
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
State of Tennessee
Division of Claims and Risk Management
502 Deaderick Street
Nashville, Tennessee 37243-0202
Telephone: (615) 741-2734 w Fax: (615) 532-4979
Website: www.treasury.tn.gov/injury
E-mail: Criminal.Injury@tn.gov
A Division of the Tennessee Treasury Department
CRIMINAL INJURIES COMPENSATION APPLICATION
Medical Bills
Mental Health Counseling Bills - Services must be for the
vicm or, in some cases, a relave of the vicm.
Lost Wages - You must complete Secon F of the applicaon
and aach the paperwork described there.
Permanent Impairment - Provide a doctor’s statement with
your impairment rang due to the injury from the crime.
Funeral and/or Burial Expenses
Crime Scene Cleanup Expenses
FOR OFFICE USE ONLY
SECTION A - ELIGIBLE EXPENSES
SECTION B - VICTIM INFORMATION continued)
Tell us about the person who was injured or has died from injuries in the crime.
Is this person (the vicm) deceased?
* No * Yes
Vicm’s Name __________________________________________________________________________________________
(Last) (First) (Maiden) (Middle)
Street Address ____________________________________________________ Apt./Unit/Lot Number _______________
__________________________________________________________________________________________
(City) (County) (State) (Zip Code)
Phone Number ___________________________________ Alternate Phone Number _______________________________
Date of Birth ___ ___ /___ ___ / ___ ___ ___ ___ Age at Time of Crime _______________________________
( mm / dd / yyyy)
___ ___ ___ - ___ ___ -___ ___ ___ ___ or ___ ___ ___ - ___ ___ -___ ___ ___ ___
Social Security Number Individual Taxpayer ID Number
Page 2 of 5
If you are not the vicm named and described in Secon B, please tell us which of these describes you:
Guardian of a Vicm Who is Under 18 Years of Age - Provide a copy of the child’s birth cercate or the guardianship
papers if you are not the child’s parent.
Representave of an Adult Vicm - Provide documentaon to show you have the legal right to le on the vicm’s behalf.
Dependent of the Deceased Vicm - A dependent means a family member who was receiving substanal support or
needed services at the me of the vicm’s death. Submit proof of your relaonship to the vicm (e.g. marriage cercate,
birth cercate, etc.).
Guardian of a Dependent of the Deceased Vicm - If the dependent is under 18 years of age, provide a copy of the birth
cercate and the guardianship papers. If the dependent is an adult who is incompetent, provide a copy of the guardianship/
conservatorship or other papers.
Relave of the Deceased Vicm Filing for Funeral/Burial, Crime Scene Clean-Up, Trial Travel, and/or Mental Health
Counseling Expenses
If you are not the vicm named in Secon B, and you are one of the persons described above, provide your informaon below
and answer the following queson:
How do you know the vicm? The vicm is my _______________________________________________________________ .
Claimant’s Name ________________________________________________________________________________________
(Last) (First) (Maiden) (Middle)
Street Address ____________________________________________________ Apt./Unit/Lot Number _______________
City ________________________________ County __________________________ State ______ Zip Code ___________
Phone Number ___________________________________ Alternate Phone Number _______________________________
Date of Birth ___ ___ /___ ___ / ___ ___ ___ ___ ( mm / dd / yyyy)
___ ___ ___ - ___ ___ -___ ___ ___ ___ or ___ ___ ___ - ___ ___ -___ ___ ___ ___
Social Security Number Individual Taxpayer ID Number
SECTION C (PART 1): CLAIMANT INFORMATION
Page 3 of 5
Did the vicm contribute nancial support to any dependents at the me of death? * No * Yes
If no, skip to Secon D.
If yes, submit proof of relaonship to the vicm and provide documentaon that the vicm substanally supported the
relave(s) at the me of death (e.g., tax returns, receipts, order for child support). Also, aach vericaon of the vicm’s
income at the me of death (e.g., employer’s statement, W-2 form or tax return).
Provide names of the deceased vicm’s dependents for whom you are ling a claim for loss of support. If available, please
submit a copy of the vicm’s obituary noce.
Name Street Address City / State / Zip Code
Relaon
to Vicm Birth Date
Did the vicm leave other dependents who are not listed above?
* No * Yes
If yes, please provide their names and addresses below. Aach addional pages if necessary.
Name Street Address City / State / Zip Code
Relaon
to Vicm Birth Date
SECTION C (PART 2): DECEASED VICTIM’S DEPENDENTS/LOSS OF SUPPORT
SECTION B - VICTIM INFORMATION
Please check the expenses below that you want this program to consider. Aach fully itemized bills to document all expenses.
Also, include proof of any payments made by you or other sources.
Loss of Support to Dependents (in case of vicm’s
death) - You must complete all of Secon C and
provide the paperwork described there.
Pain and Suering - (ONLY for the vicm of a sexually-
oriented crime.)
Moving Expenses - (ONLY for a vicm if the crime
occurred in the primary residence and the move is
directly related to the crime.)
Trial Travel Expenses - (To aend trial of the defendant
unless person is eligible for witness fees from the state
or federal prosecutor’s oce.)
Please answer these quesons about the vicm named on page 1 (used for stascal purposes only):
Mentally Disabled?
* No * Yes Physically Disabled? * No * Yes
Race
* American Indian/Alaska Nave * Mulple Races
* Asian * Nave Hawaiian/Pacic Islander
* Black/African American * White/Caucasian
* Hispanic or Lano * Other (specify) __________________________
Gender
* Male * Female
Naonal Origin
* United States * Other _________________________________
Who told you about this program?
* Hospital * Posters/Brochure
* Internet/Web Search * Prosecutor/Vicm Witness Program
* Law Enforcement * Social Services
* Media (TV, radio, etc.) * Other (specify) __________________________

Page 1 of 5
SECTION D - CRIME INFORMATION
You must provide the date of the crime and county and state where the crime occurred. You can obtain the informaon from
the responding law enforcement agency. If the crime was not reported within 48 hours, submit a wrien statement explaining
why.
Type of Crime (check one):
* Murder/Homicide * Child Physical Abuse * Kidnapping
* Adult Sexual Assault * Child Sexual Abuse * Arson
* Robbery by Force * Drunk Driver/DUI * Hit and Run (excluding property damage)
* Assault * Stalking * Human Tracking
* Vehicular (Non-DUI) * Terrorism * Other (specify) ______________________
Was the crime domesc violence?
* No * Yes Did the crime occur inside the vicm’s home? * No * Yes
Date of Crime: ___ ___ /___ ___ / ___ ___ ___ ___ Date Reported to Law Enforcement: ___ ___ /___ ___ / ___ ___ ___ ___
( mm / dd / yyyy) ( mm / dd / yyyy)
Locaon of Crime: _______________________________________________________________________________________
(Street) (City) (County, required) (State, required)
Was the injury or death of the vicm caused by a motor vehicle?
* No * Yes
Reset Form
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
State of Tennessee
Division of Claims Administration
502 Deaderick Street
Nashville, Tennessee 37243-0202
Telephone: (615) 741-2734 w Fax: (615) 532-4979
Website: www.treasury.tn.gov/injury
E-mail: Criminal.Injury@tn.gov
A Division of the Tennessee Treasury Department
CRIMINAL INJURIES COMPENSATION APPLICATION
Medical Bills
Mental Health Counseling Bills - Services must be for the
vicm or, in some cases, a relave of the vicm.
Lost Wages - You must complete Secon F of the applicaon
and aach the paperwork described there.
Permanent Impairment - Provide a doctor’s statement with
your impairment rang due to the injury from the crime.
Funeral and/or Burial Expenses
Crime Scene Cleanup Expenses
FOR OFFICE USE ONLY
SECTION A - ELIGIBLE EXPENSES
SECTION B - VICTIM INFORMATION continued)
Tell us about the person who was injured or has died from injuries in the crime.
Is this person (the vicm) deceased?
* No * Yes
Vicm’s Name __________________________________________________________________________________________
(Last) (First) (Maiden) (Middle)
Street Address ____________________________________________________ Apt./Unit/Lot Number _______________
__________________________________________________________________________________________
(City) (County) (State) (Zip Code)
Phone Number ___________________________________ Alternate Phone Number _______________________________
Date of Birth ___ ___ /___ ___ / ___ ___ ___ ___ Age at Time of Crime _______________________________
( mm / dd / yyyy)
___ ___ ___ - ___ ___ -___ ___ ___ ___ or ___ ___ ___ - ___ ___ -___ ___ ___ ___
Social Security Number Individual Taxpayer ID Number
Page 2 of 5
If you are not the vicm named and described in Secon B, please tell us which of these describes you:
Guardian of a Vicm Who is Under 18 Years of Age - Provide a copy of the child’s birth cercate or the guardianship
papers if you are not the child’s parent.
Representave of an Adult Vicm - Provide documentaon to show you have the legal right to le on the vicm’s behalf.
Dependent of the Deceased Vicm - A dependent means a family member who was receiving substanal support or
needed services at the me of the vicm’s death. Submit proof of your relaonship to the vicm (e.g. marriage cercate,
birth cercate, etc.).
Guardian of a Dependent of the Deceased Vicm - If the dependent is under 18 years of age, provide a copy of the birth
cercate and the guardianship papers. If the dependent is an adult who is incompetent, provide a copy of the guardianship/
conservatorship or other papers.
Relave of the Deceased Vicm Filing for Funeral/Burial, Crime Scene Clean-Up, Trial Travel, and/or Mental Health
Counseling Expenses
If you are not the vicm named in Secon B, and you are one of the persons described above, provide your informaon below
and answer the following queson:
How do you know the vicm? The vicm is my _______________________________________________________________ .
Claimant’s Name ________________________________________________________________________________________
(Last) (First) (Maiden) (Middle)
Street Address ____________________________________________________ Apt./Unit/Lot Number _______________
City ________________________________ County __________________________ State ______ Zip Code ___________
Phone Number ___________________________________ Alternate Phone Number _______________________________
Date of Birth ___ ___ /___ ___ / ___ ___ ___ ___ ( mm / dd / yyyy)
___ ___ ___ - ___ ___ -___ ___ ___ ___ or ___ ___ ___ - ___ ___ -___ ___ ___ ___
Social Security Number Individual Taxpayer ID Number
SECTION C (PART 1): CLAIMANT INFORMATION
Page 3 of 5
Did the vicm contribute nancial support to any dependents at the me of death? * No * Yes
If no, skip to Secon D.
If yes, submit proof of relaonship to the vicm and provide documentaon that the vicm substanally supported the
relave(s) at the me of death (e.g., tax returns, receipts, order for child support). Also, aach vericaon of the vicm’s
income at the me of death (e.g., employer’s statement, W-2 form or tax return).
Provide names of the deceased vicm’s dependents for whom you are ling a claim for loss of support. If available, please
submit a copy of the vicm’s obituary noce.
Name Street Address City / State / Zip Code
Relaon
to Vicm Birth Date
Did the vicm leave other dependents who are not listed above?
* No * Yes
If yes, please provide their names and addresses below. Aach addional pages if necessary.
Name Street Address City / State / Zip Code
Relaon
to Vicm Birth Date
SECTION C (PART 2): DECEASED VICTIM’S DEPENDENTS/LOSS OF SUPPORT
SECTION B - VICTIM INFORMATION
Please check the expenses below that you want this program to consider. Aach fully itemized bills to document all expenses.
Also, include proof of any payments made by you or other sources.
Loss of Support to Dependents (in case of vicm’s
death) - You must complete all of Secon C and
provide the paperwork described there.
Pain and Suering - (ONLY for the vicm of a sexually-
oriented crime.)
Moving Expenses - (ONLY for a vicm if the crime
occurred in the primary residence and the move is
directly related to the crime.)
Trial Travel Expenses - (To aend trial of the defendant
unless person is eligible for witness fees from the state
or federal prosecutor’s oce.)
Please answer these quesons about the vicm named on page 1 (used for stascal purposes only):
Mentally Disabled?
* No * Yes Physically Disabled? * No * Yes
Race
* American Indian/Alaska Nave * Mulple Races
* Asian * Nave Hawaiian/Pacic Islander
* Black/African American * White/Caucasian
* Hispanic or Lano * Other (specify) __________________________
Gender
* Male * Female
Naonal Origin
* United States * Other _________________________________
Who told you about this program?
* Hospital * Posters/Brochure
* Internet/Web Search * Prosecutor/Vicm Witness Program
* Law Enforcement * Social Services
* Media (TV, radio, etc.) * Other (specify) __________________________

Page 1 of 5
SECTION D - CRIME INFORMATION
You must provide the date of the crime and county and state where the crime occurred. You can obtain the informaon from
the responding law enforcement agency. If the crime was not reported within 48 hours, submit a wrien statement explaining
why.
Type of Crime (check one):
* Murder/Homicide * Child Physical Abuse * Kidnapping
* Adult Sexual Assault * Child Sexual Abuse * Arson
* Robbery by Force * Drunk Driver/DUI * Hit and Run (excluding property damage)
* Assault * Stalking * Human Tracking
* Vehicular (Non-DUI) * Terrorism * Other (specify) ______________________
Was the crime domesc violence?
* No * Yes Did the crime occur inside the vicm’s home? * No * Yes
Date of Crime: ___ ___ /___ ___ / ___ ___ ___ ___ Date Reported to Law Enforcement: ___ ___ /___ ___ / ___ ___ ___ ___
( mm / dd / yyyy) ( mm / dd / yyyy)
Locaon of Crime: _______________________________________________________________________________________
(Street) (City) (County, required) (State, required)
Was the injury or death of the vicm caused by a motor vehicle?
* No * Yes
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
State of Tennessee
Division of Claims Administration
502 Deaderick Street
Nashville, Tennessee 37243-0202
Telephone: (615) 741-2734 w Fax: (615) 532-4979
Website: www.treasury.tn.gov/injury
E-mail: Criminal.Injury@tn.gov
A Division of the Tennessee Treasury Department
CRIMINAL INJURIES COMPENSATION APPLICATION
Medical Bills
Mental Health Counseling Bills - Services must be for the
vicm or, in some cases, a relave of the vicm.
Lost Wages - You must complete Secon F of the applicaon
and aach the paperwork described there.
Permanent Impairment - Provide a doctor’s statement with
your impairment rang due to the injury from the crime.
Funeral and/or Burial Expenses
Crime Scene Cleanup Expenses
FOR OFFICE USE ONLY
SECTION A - ELIGIBLE EXPENSES
SECTION B - VICTIM INFORMATION continued)
Tell us about the person who was injured or has died from injuries in the crime.
Is this person (the vicm) deceased?
* No * Yes
Vicm’s Name __________________________________________________________________________________________
(Last) (First) (Maiden) (Middle)
Street Address ____________________________________________________ Apt./Unit/Lot Number _______________
__________________________________________________________________________________________
(City) (County) (State) (Zip Code)
Phone Number ___________________________________ Alternate Phone Number _______________________________
Date of Birth ___ ___ /___ ___ / ___ ___ ___ ___ Age at Time of Crime _______________________________
( mm / dd / yyyy)
___ ___ ___ - ___ ___ -___ ___ ___ ___ or ___ ___ ___ - ___ ___ -___ ___ ___ ___
Social Security Number Individual Taxpayer ID Number
Page 2 of 5
If you are not the vicm named and described in Secon B, please tell us which of these describes you:
Guardian of a Vicm Who is Under 18 Years of Age - Provide a copy of the child’s birth cercate or the guardianship
papers if you are not the child’s parent.
Representave of an Adult Vicm - Provide documentaon to show you have the legal right to le on the vicm’s behalf.
Dependent of the Deceased Vicm - A dependent means a family member who was receiving substanal support or
needed services at the me of the vicm’s death. Submit proof of your relaonship to the vicm (e.g. marriage cercate,
birth cercate, etc.).
Guardian of a Dependent of the Deceased Vicm - If the dependent is under 18 years of age, provide a copy of the birth
cercate and the guardianship papers. If the dependent is an adult who is incompetent, provide a copy of the guardianship/
conservatorship or other papers.
Relave of the Deceased Vicm Filing for Funeral/Burial, Crime Scene Clean-Up, Trial Travel, and/or Mental Health
Counseling Expenses
If you are not the vicm named in Secon B, and you are one of the persons described above, provide your informaon below
and answer the following queson:
How do you know the vicm? The vicm is my _______________________________________________________________ .
Claimant’s Name ________________________________________________________________________________________
(Last) (First) (Maiden) (Middle)
Street Address ____________________________________________________ Apt./Unit/Lot Number _______________
City ________________________________ County __________________________ State ______ Zip Code ___________
Phone Number ___________________________________ Alternate Phone Number _______________________________
Date of Birth ___ ___ /___ ___ / ___ ___ ___ ___ ( mm / dd / yyyy)
___ ___ ___ - ___ ___ -___ ___ ___ ___ or ___ ___ ___ - ___ ___ -___ ___ ___ ___
Social Security Number Individual Taxpayer ID Number
SECTION C (PART 1): CLAIMANT INFORMATION
Page 3 of 5
Did the vicm contribute nancial support to any dependents at the me of death? * No * Yes
If no, skip to Secon D.
If yes, submit proof of relaonship to the vicm and provide documentaon that the vicm substanally supported the
relave(s) at the me of death (e.g., tax returns, receipts, order for child support). Also, aach vericaon of the vicm’s
income at the me of death (e.g., employer’s statement, W-2 form or tax return).
Provide names of the deceased vicm’s dependents for whom you are ling a claim for loss of support. If available, please
submit a copy of the vicm’s obituary noce.
Name Street Address City / State / Zip Code
Relaon
to Vicm Birth Date
Did the vicm leave other dependents who are not listed above?
* No * Yes
If yes, please provide their names and addresses below. Aach addional pages if necessary.
Name Street Address City / State / Zip Code
Relaon
to Vicm Birth Date
SECTION C (PART 2): DECEASED VICTIM’S DEPENDENTS/LOSS OF SUPPORT
SECTION B - VICTIM INFORMATION
Please check the expenses below that you want this program to consider. Aach fully itemized bills to document all expenses.
Also, include proof of any payments made by you or other sources.
Loss of Support to Dependents (in case of vicm’s
death) - You must complete all of Secon C and
provide the paperwork described there.
Pain and Suering - (ONLY for the vicm of a sexually-
oriented crime.)
Moving Expenses - (ONLY for a vicm if the crime
occurred in the primary residence and the move is
directly related to the crime.)
Trial Travel Expenses - (To aend trial of the defendant
unless person is eligible for witness fees from the state
or federal prosecutor’s oce.)
Please answer these quesons about the vicm named on page 1 (used for stascal purposes only):
Mentally Disabled?
* No * Yes Physically Disabled? * No * Yes
Race
* American Indian/Alaska Nave * Mulple Races
* Asian * Nave Hawaiian/Pacic Islander
* Black/African American * White/Caucasian
* Hispanic or Lano * Other (specify) __________________________
Gender
* Male * Female
Naonal Origin
* United States * Other _________________________________
Who told you about this program?
* Hospital * Posters/Brochure
* Internet/Web Search * Prosecutor/Vicm Witness Program
* Law Enforcement * Social Services
* Media (TV, radio, etc.) * Other (specify) __________________________

Page 1 of 5
SECTION D - CRIME INFORMATION
You must provide the date of the crime and county and state where the crime occurred. You can obtain the informaon from
the responding law enforcement agency. If the crime was not reported within 48 hours, submit a wrien statement explaining
why.
Type of Crime (check one):
* Murder/Homicide * Child Physical Abuse * Kidnapping
* Adult Sexual Assault * Child Sexual Abuse * Arson
* Robbery by Force * Drunk Driver/DUI * Hit and Run (excluding property damage)
* Assault * Stalking * Human Tracking
* Vehicular (Non-DUI) * Terrorism * Other (specify) ______________________
Was the crime domesc violence?
* No * Yes Did the crime occur inside the vicm’s home? * No * Yes
Date of Crime: ___ ___ /___ ___ / ___ ___ ___ ___ Date Reported to Law Enforcement: ___ ___ /___ ___ / ___ ___ ___ ___
( mm / dd / yyyy) ( mm / dd / yyyy)
Locaon of Crime: _______________________________________________________________________________________
(Street) (City) (County, required) (State, required)
Was the injury or death of the vicm caused by a motor vehicle?
* No * Yes
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
State of Tennessee
Division of Claims Administration
502 Deaderick Street w Nashville, Tennessee 37243-0202
Telephone: (615) 741-2734 w Fax: (615) 532-4979
Website: www.treasury.tn.gov/injury
E-mail: Criminal.Injury@tn.gov
A Division of the Tennessee Treasury Department
TENNESSEE CRIMINAL INJURIES COMPENSATION APPLICATION
PURPOSE
When a person is injured in a crime in the state of Tennessee, that vicm or certain family members may apply to the
Tennessee Criminal Injuries Compensaon Program for help with the injury-related expenses. The program is managed by the
Tennessee Treasury Department’s Division of Claims Administraon. The goal of the program is to ease the nancial burden of
crimes involving injury whenever the vicm or family members meet certain requirements. The program can approve a claim
only if the vicm meets eligibility requirements, if the crime involves injury and is a type of crime the program can consider,
and if the expenses covered by the program are properly documented.
APPLICATION INSTRUCTIONS
; File an applicaon within one year of the date of injury or death. If the vicm is under 18 years of age, the legal guardian
must le the claim on behalf of the minor vicm. The guardian may le the claim unl the vicm reaches 18 years of age.
An adult who was vicmized as a minor, or who lost nancial support as a minor due to the death of a vicm, may le on
his/her behalf unl he/she reaches age 19.
; Complete all pages of the applicaon. If compleng by hand, use BLACK or BLUE INK. Please print clearly. Answer all
quesons. Unanswered quesons will slow or prevent the processing of the applicaon. The person ling the claim must
sign Secon G in the presence of a notary.
; You are not required to have an aorney complete this applicaon. If you wish, however, you may do so. Any
communicaon about your claim will be directly through your aorney, and he/she may be eligible for aorney fees.
; Submit the applicaon to the program oce at the address on the top of this page. The applicaon is not “led” unl the
Division of Claims Administraon receives all completed pages by mail or by fax. Call (615) 741-2734 and ask to speak to a
Customer Service Representave if you have quesons about the applicaon.
; The expenses you want the program to consider must be rst led with any/all other public or private sources of
assistance, such as health, life, burial, and/or auto insurance, workers’ compensaon, sick leave/vacaon pay, etc. The
program can only consider those expenses the vicm or relave must pay out of pocket. This is a fund of last resort.
; Aach copies of itemized bills from service providers, receipts, insurance benet statements, and any other
documentaon to support the expenses you wish the program to consider. Refer to the list of eligible expenses on the rst
page of the applicaon if you are not sure the expense can be considered.
; Respond as soon as possible to any leers from our oce.
; Nofy our oce immediately if there is any change in your address or phone number while the claim is being processed.
The claim may be denied if we have no valid contact informaon.
e Tennessee Department of Treasury operates all programs and activities free from discrimination on the basis of sex, race, or
any other classication protected by federal or Tennessee state laws. Individuals with disabilities who may require an alternative
communication format for this or other Treasury Department publications should contact Treasury Department Human Resources
at 615-253-8769. Any person who believes she or he has been discriminated against in Treasury Department programs should write
to: Title VI Coordinator, Treasury Department Human Resources, Andrew Jackson Building, 13th Floor, Nashville, Tennessee 37243.
VERIFICATION OF APPLICATION: I hereby cerfy, subject to the penalty of ne and imprisonment, that the informaon contained in
this applicaon for criminal injuries compensaon is true and correct to the best of my knowledge.
SUBROGATION: In consideraon of the payment received from the Criminal Injuries Compensaon Fund, I agree to repay the Fund
the full amount I (or my child or ward) received from the Fund in the event I (or my child or ward) recover damages or compensaon
from the oender or from any other public or private source as a result of the injuries or death which was the basis of my claim for
compensaon from the Fund. For purposes of this Agreement, I understand that compensaon from “any other public or private
source” includes, but is not limited to, receipt of insurance, Medicare, Medicaid, TennCare, workers’ compensaon, disability pay,
etc. I further agree and understand that no part of the recovery due the Criminal Injuries Compensaon Fund may be diminished by
any collecon fees or for any other reason whatsoever. Should I (or my child or ward) choose to recover damages or compensaon
for the injury or death from any source, I agree to promptly nofy the District Aorney General in the district where the crime
occurred and the Criminal Injuries Compensaon Program by sending to the District Aorney General and the Compensaon
Program copies of any pleadings, selement proposals and any other documents relave thereto. I further agree to fully cooperate
with the State of Tennessee should the State instute an acon against any person or enty for the recovery of all or any part of the
compensaon I (or my child or ward) received from the Fund.
RELEASE OF INFORMATION AUTHORIZATION: I hereby authorize any hospital, physician, funeral director, municipal authority,
employer or union, insurance company, social service bureau, Social Security oce, or any other person, rm, agency, or organizaon
to furnish to the Tennessee Criminal Injuries Compensaon Fund, or its representave, any informaon requested, including tax data
and prior police records, needed to perfect my claim for compensaon. A photocopy of this authorizaon shall be considered as
eecve and valid as the original.
PUBLIC RECORDS: Except as otherwise provided by applicable federal or state law, the informaon contained in this applicaon
and all documents submied in support of your claim are subject to the Public Records Laws of the State of Tennessee pursuant to
Tennessee Code Annotated, Title 10, Chapter 7, Part 5.
I cerfy that I have read and/or understand and agree to the above statements.
Vicm/Claimant’s Signature: _________________________________________ Date: _______________________________
Vicm/Claimant’s Printed Name: ______________________________________
State of ______________ / County of ___________________
Sworn to and subscribed before me, the undersigned Notary, on this, the ________ day of ______________________, 20 ________ .
(SEAL) Notary’s Signature: __________________________________
My Commission Expires: _____________________________
SECTION G - AUTHORIZATION AND SUBROGATION
SECTION H - ATTORNEY INFORMATION
Page 4 of 5
SECTION E - INSURANCE AND FINANCIAL ASSISTANCE
Is there any benet program, employer benet, or insurance coverage to assist with the expenses being claimed?
* No * Yes
If yes, please check below the benets that have been paid (or may be paid), in part or in full, for any expenses you are
claiming. Also, provide documentaon of payments made.
* Automobile Insurance * Homeowner’s Insurance * Social Security (death benets, disability, etc.)
* Burial Insurance * Life Insurance * Vacaon/Annual Pay
* Disability * Medicare/Medicaid/TennCare * Veterans Administraon/Insurance
* Donaons * Oender/Court-Ordered Restuon * Workers’ Compensaon
* Health Insurance * Sick Pay * Other (specify) ________________________
Has the court ordered the oender to pay you for your nancial losses?
* No * Yes
If yes, please aach a copy of the order of restuon.
Have you led or do you plan to le a lawsuit for your injuries?
* No * Yes * Unknown
If yes, and you are represented by an aorney, please provide the aorney’s name and telephone number.
___________________________________________________________________________________________________
Page 5 of 5
Please describe what happened and the injuries suered as a result. Aach a copy of the police report.
Also, please aach a copy of the death cercate if the vicm is deceased.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Name and address of offender(s), if known.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Did the vicm know the oender(s)?
* No * Yes If yes, in what way? __ ____________________________________
Was the vicm living in the same house with the oender at the me of the crime?
* No * Yes
Does the vicm sll live with the oender?
* No * Yes
Who is handling the criminal case?
* State Prosecutor * Federal Prosecutor
SECTION D - CRIME INFORMATION continued
SECTION F - LOST WAGES
Complete this secon only if you are the vicm named in Secon B and you are claiming lost wages from your job at the me
of injury. Informaon needed to verify lost wages is described below. DO NOT complete this secon if the vicm is deceased.
Did you, the vicm, miss work due to injuries?
* No * Yes
If yes, please have your employer(s) complete an Employer’s Statement form. If you missed more than two weeks of work,
please provide a doctor’s statement or a doctor’s release to return to work.
Were you self-employed at the me of the crime?
* No * Yes
If yes, submit the most recent income tax return or statements from those for whom the vicm worked, showing
amount(s) paid and date(s) for a period of at least 12 months prior to the crime. If you missed more than two weeks of
work, please provide a doctor’s statement or a doctor’s release to return to work.
If you choose an aorney to complete the applicaon for you, the aorney must complete and sign this secon. NOTE: This is not
the state or federal prosecutor handling the criminal case.
Aorney’s Full Name: _________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
(Street) (City) (County) (State) (Zip Code)
Phone Number: _____________________________________ FEIN or SSN: ___ ___ ___ ___ ___ ___ ___ ___ ___
 - I hereby cerfy that I have been retained by and represent the vicm and/or claimant ling this applicaon.
I further cerfy that I have read through this enre applicaon with such person and that such person indicated that he/she
understood every queson and provision contained herein.
Aorney’s Signature/Date: __________________________________________
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
TR-0300 (Rev. 9/17)
RDA 1178
State of Tennessee
Division of Claims Administration
502 Deaderick Street w Nashville, Tennessee 37243-0202
Telephone: (615) 741-2734 w Fax: (615) 532-4979
Website: www.treasury.tn.gov/injury
E-mail: Criminal.Injury@tn.gov
A Division of the Tennessee Treasury Department
TENNESSEE CRIMINAL INJURIES COMPENSATION APPLICATION
PURPOSE
When a person is injured in a crime in the state of Tennessee, that vicm or certain family members may apply to the
Tennessee Criminal Injuries Compensaon Program for help with the injury-related expenses. The program is managed by the
Tennessee Treasury Department’s Division of Claims Administraon. The goal of the program is to ease the nancial burden of
crimes involving injury whenever the vicm or family members meet certain requirements. The program can approve a claim
only if the vicm meets eligibility requirements, if the crime involves injury and is a type of crime the program can consider,
and if the expenses covered by the program are properly documented.
APPLICATION INSTRUCTIONS
; File an applicaon within one year of the date of injury or death. If the vicm is under 18 years of age, the legal guardian
must le the claim on behalf of the minor vicm. The guardian may le the claim unl the vicm reaches 18 years of age.
An adult who was vicmized as a minor, or who lost nancial support as a minor due to the death of a vicm, may le on
his/her behalf unl he/she reaches age 19.
; Complete all pages of the applicaon. If compleng by hand, use BLACK or BLUE INK. Please print clearly. Answer all
quesons. Unanswered quesons will slow or prevent the processing of the applicaon. The person ling the claim must
sign Secon G in the presence of a notary.
; You are not required to have an aorney complete this applicaon. If you wish, however, you may do so. Any
communicaon about your claim will be directly through your aorney, and he/she may be eligible for aorney fees.
; Submit the applicaon to the program oce at the address on the top of this page. The applicaon is not “led” unl the
Division of Claims Administraon receives all completed pages by mail or by fax. Call (615) 741-2734 and ask to speak to a
Customer Service Representav ve quesons about the applicaon.
; The expenses you want the program to consider must be rst led with any/all other public or private sources of
assistance, such as health, life, burial, and/or auto insurance, workers’ compensaon, sick leave/vacaon pay, etc. The
program can only consider those expenses the vicm or relave must pay out of pocket. This is a fund of last resort.
; Aach copies of itemized bills from service providers, receipts, insurance benet statements, and any other
documentaon to support the expenses you wish the program to consider. Refer to the list of eligible expenses on the rst
page of the applicaon if you are not sure the expense can be considered.
; Respond as soon as possible to any leers from our oce.
; Nofy our oce immediately if there is any change in your address or phone number while the claim is being processed.
The claim may be denied if we have no valid contact informaon.
e Tennessee Department of Treasury operates all programs and activities free from discrimination on the basis of sex, race, or
any other classication protected by federal or Tennessee state laws. Individuals with disabilities who may require an alternative
communication format for this or other Treasury Department publications should contact Treasury Department Human Resources
at 615-253-8769. Any person who believes she or he has been discriminated against in Treasury Department programs should write
to: Title VI Coordinator, Treasury Department Human Resources, Andrew Jackson Building, 13th Floor, Nashville, Tennessee 37243.
VERIFICATION OF APPLICATION: I hereby cerfy, subject to the penalty of ne and imprisonment, that the informaon contained in
this applicaon for criminal injuries compensaon is true and correct to the best of my knowledge.
SUBROGATION: In consideraon of the payment received from the Criminal Injuries Compensaon Fund, I agree to repay the Fund
the full amount I (or my child or ward) received from the Fund in the event I (or my child or ward) recover damages or compensaon
from the oender or from any other public or private source as a result of the injuries or death which was the basis of my claim for
compensaon from the Fund. For purposes of this Agreement, I understand that compensaon from “any other public or private
source” includes, but is not limited to, receipt of insurance, Medicare, Medicaid, TennCare, workers’ compensaon, disability pay,
etc. I further agree and understand that no part of the recovery due the Criminal Injuries Compensaon Fund may be diminished by
any collecon fees or for any other reason whatsoever. Should I (or my child or ward) choose to recover damages or compensaon
for the injury or death from any source, I agree to promptly nofy the District Aorney General in the district where the crime
occurred and the Criminal Injuries Compensaon Program by sending to the District Aorney General and the Compensaon
Program copies of any pleadings, selement proposals and any other documents relave thereto. I further agree to fully cooperate
with the State of Tennessee should the State instute an acon against any person or enty for the recovery of all or any part of the
compensaon I (or my child or ward) received from the Fund.
RELEASE OF INFORMATION AUTHORIZATION: I hereby authorize any hospital, physician, funeral director, municipal authority,
employer or union, insurance company, social service bureau, Social Security oce, or any other person, rm, agency, or organizaon
to furnish to the Tennessee Criminal Injuries Compensaon Fund, or its representave, any informaon requested, including tax data
and prior police records, needed to perfect my claim for compensaon. A photocopy of this authorizaon shall be considered as
eecve and valid as the original.
PUBLIC RECORDS: Except as otherwise provided by applicable federal or state law, the informaon contained in this applicaon
and all documents submied in support of your claim are subject to the Public Records Laws of the State of Tennessee pursuant to
Tennessee Code Annotated, Title 10, Chapter 7, Part 5.
I cerfy that I have read and/or understand and agree to the above statements.
Vicm/Claimant’s Signature: _________________________________________ Date: _______________________________
Vicm/Claimant’s Printed Name: ______________________________________
State of ______________ / County of ___________________
Sworn to and subscribed before me, the undersigned Notary, on this, the ________ day of ______________________, 20 ________ .
(SEAL) Notary’s Signature: __________________________________
My Commission Expires: _____________________________
SECTION G - AUTHORIZATION AND SUBROGATION
SECTION H - ATTORNEY INFORMATION
Page 4 of 5
SECTION E - INSURANCE AND FINANCIAL ASSISTANCE
Is there any benet program, employer benet, or insurance coverage to assist with the expenses being claimed?
* No * Yes
If yes, please check below the benets that have been paid (or may be paid), in part or in full, for any expenses you are
claiming. Also, provide documentaon of payments made.
* Automobile Insurance * Homeowner’s Insurance * Social Security (death benets, disability, etc.)
* Burial Insurance * Life Insurance * Vacaon/Annual Pay
* Disability * Medicare/Medicaid/TennCare * Veterans Administraon/Insurance
* Donaons * Oender/Court-Ordered Restuon * Workers’ Compensaon
* Health Insurance * Sick Pay * Other (specify) ________________________
Has the court ordered the oender to pay you for your nancial losses?
* No * Yes
If yes, please aach a copy of the order of restuon.
Have you led or do you plan to le a lawsuit for your injuries?
* No * Yes * Unknown
If yes, and you are represented by an aorney, please provide the aorney’s name and telephone number.
___________________________________________________________________________________________________
Page 5 of 5
Please describe what happened and the injuries suered as a result. Aach a copy of the police report.
Also, please aach a copy of the death cercate if the vicm is deceased.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Name and address of oender(s), if known. (By law, we are required to nofy oender(s) of this claim.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Did the vicm know the oender(s)?
* No * Yes If yes, in what way? ______________________________________
Was the vicm living in the same house with the oender at the me of the crime?
* No * Yes
Does the vicm sll live with the oender?
* No * Yes
Who is handling the criminal case?
* State Prosecutor * Federal Prosecutor
SECTION D - CRIME INFORMATION continued
SECTION F - LOST WAGES
Complete this secon only if you are the vicm named in Secon B and you are claiming lost wages from your job at the me
of injury. Informaon needed to verify lost wages is described below. DO NOT complete this secon if the vicm is deceased.
Did you, the vicm, miss work due to injuries?
* No * Yes
If yes, please have your employer(s) complete an Employer’s Statement form. If you missed more than two weeks of work,
please provide a doctor’s statement or a doctor’s release to return to work.
Were you self-employed at the me of the crime?
* No * Yes
If yes, submit the most recent income tax return or statements from those for whom the vicm worked, showing
amount(s) paid and date(s) for a period of at least 12 months prior to the crime. If you missed more than two weeks of
work, please provide a doctor’s statement or a doctor’s release to return to work.
If you choose an aorney to complete the applicaon for you, the aorney must complete and sign this secon. NOTE: This is not
the state or federal prosecutor handling the criminal case.
Aorney’s Full Name: _________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
(Street) (City) (County) (State) (Zip Code)
Phone Number: _____________________________________ FEIN or SSN: ___ ___ ___ ___ ___ ___ ___ ___ ___
 - I hereby cerfy that I have been retained by and represent the vicm and/or claimant ling this applicaon.
I further cerfy that I have read through this enre applicaon with such person and that such person indicated that he/she
understood every queson and provision contained herein.
Aorney’s Signature/Date: __________________________________________
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TENNESSEE CRIMINAL INJURIES COMPENSATION APPLICATION (State of Tennessee)

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Completed 8 May 2021

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