Fillable TEXAS CRIME VICTIMS COMPENSATION PROGRAM APPLICATION

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TEXAS CRIME VICTIMS COMPENSATION PROGRAM APPLICATION

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Page 1 of 9
TEXAS CRIME VICTIMS’ COMPENSATION PROGRAM
APPLICATION
Nota: Si tiene alguna pregunta sobre esta solicitud o si la desea en espanol, favor de llamar al
Programa de
Compensación para las Victimas de Crimen al (512) 936-1200 o (800) 983-9933.
Please read the directions on this page before completing the application. Reading these instructions will help you
complete
each section correctly.
Include all the documentation you can. If you have a copy of the police report, protective order with affidavit, hospital or
doctor
bills, health insurance card, or auto insurance declaration page (if the crime is auto-related), be sure to send
them with the
application.
If you require additional space on any section of the application, please attach a separate sheet of paper and include all
the
required information.
If you do not have this documentation, do not wait to mail the application. Send the application as soon as you have
completed
it. Collect all additional information so that you will have it when we contact you.
Keep this page so that you will have our address and phone number. Mail your completed application to:
Office of the Attorney General
Crime Victims' Compensation Program (011)
P.O. Box 12198
Austin, Texas 78711-2198
If your address or phone number changes, it is important that you let us know. The toll-free number for victims,
claimants and service providers is (800) 983-9933. Austin callers should use (512) 936-1200. For security reasons,
the Crime Victims' Compensation Program does not routinely communicate with victims via email. In some cases where
security is not an issue, the CVC Program may use email to inform a victim or claimant of the status of the claim.
If you need help completing this application, contact your local law enforcement agency's Crime Victim Liaison or
your local District Attorney's Victim Assistance Coordinator. The Crime Victims' Compensation staff is also available
to help by phone, or you may access our website at www.texasattorneygeneral.gov to find more information on the
program.
GENERAL INFORMATION
What is the Crime Victims' Compensation (CVC) Program?
The CVC Program may provide financial assistance to victims of violent crime for related expenses that cannot be
reimbursed by insurance or other sources.
The Program is administered by the Office of the Attorney General and is committed to assisting victims and
claimants who qualify. The information provided is meant to be generally informative, and the statutory requirements
of the Texas Crime Victims' Compensation Act (Texas Code of Criminal Procedure, Chapter 56) and the rules set
forth in Title 1 of the Texas Administrative Code, Part 3, Chapter 61, govern the Program.
Money in the Victims of Crime Compensation Fund comes from fees paid by those convicted of a crime.
Keep this page for your records.
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Page 2 of 9
What are the basic eligibility requirements for Crime Victims' Compensation Program benefits?
The victim must be a resident of Texas, a United States resident who is victimized while in Texas, a Texas resident
victimized in another state or country that does not have a crime victim compensation fund, or certain other individuals.
The crime must be reported to the appropriate state or local public safety/law enforcement agency within a reasonable
period of time.
The victim or claimant must cooperate with law enforcement officials in the investigation and prosecution of the case.
NOTE: If a Medical Forensic Sexual Assault Exam was conducted on or after September 1, 2015, payments for emergency medical care
received at the same time as the exam may be available even when a victim does not report the crime or meet certain other eligibility
requirements. For more information, please visit the Crime Victims' Compensation web page or call (800) 983-9933. See Section 2a of
this application.
Who may be eligible for Crime Victims' Compensation Program benefits?
Victims of violent crime who suffer physical or mental harm as a direct result of the crime.
A victim's dependents, family or household members who qualify as claimants under the law.
Someone authorized by the victim to act on his or her behalf.
Who is not eligible for Crime Victims' Compensation Program benefits?
The offender, an accomplice of the offender or any person engaged in illegal activity at the time of the crime.
Anyone injured as a result of a motor vehicle accident, except under certain circumstances provided by law.
Benefits may be denied or reduced if the victim's or claimant's own behavior contributed to the crime.
Anyone incarcerated when the crime occurred.
Any victim or claimant who knowingly or intentionally submits, or causes to be submitted, false or forged information to the
Crime Victims' Compensation Program.
What expenses may be covered with Crime Victims' Compensation Program benefits?
Reasonable and necessary medical and funeral expenses.
Travel exceeding 20 miles one way for participation and attendance at funeral services, medical appointments and criminal
justice appointment.
Loss of earnings as a result of the disability of the victim.
Loss of earnings for investigative, judicial or medical appointments.
Loss of support to dependents of victim's, as a result of the victim's death or if the victim was supporting them at the time of
the crime.
Psychiatric care/counseling.
Counseling for the victim and eligible claimants.
Eyeglasses, hearing aids, dentures or prosthetic devices, if damaged during or needed as a result of the crime.
Crime scene clean-up.
Replacement of property seized as evidence or rendered unusable by the investigation.
New expenses for child or adult dependent care as a result of the crime.
One time rent and relocation expenses for victims of family violence, victims of sexual assault who were assaulted in their
home, victims of stalking or victims of human trafficking.
Reasonable attorney fees for assistance in filing the Crime Victims' Compensation Program application.
What expenses are not covered by Crime Victims' Compensation Program benefits?
Damage, repair or loss to property or vehicle.
Pain, suffering or emotional distress damages.
Any expense which is not the direct result of the crime.
Who is the payor of last resort?
All other available third party resources (for example, Medicare, Medicaid, personal health insurance, workers'
compensation and settlements) must meet their legal obligations to pay crime-related expenses.
The Crime Victims' Compensation Program must be notified before a civil lawsuit is filed in relation to the crime, if
restitution is ordered by the criminal court, or if any party receives the proceeds of a settlement.
CVC is considered the payor of last resort.
Keep this page for your records.
PLEASE COMPLETE ALL SECTIONS OR A DELAY MAY RESULT IN THE PROCESSING OF YOUR APPLICATION. Information about this
claim is confidential and will not be released to another person unless that person is included as a claimant or as otherwise required
by law.
What is the language preference of the victim and/or claimant?
English Spanish Other______________
SECTION 1-VICTIM INFORMATION: The victim is the person who was injured or died as a result of the crime. If the victim is a minor or
deceased, the claimant information in Section 3 MUST be completed. If there is more than one victim, each victim must submit a separate
application.
First Name
Middle Name Last Name
Mailing Address City State Zip
Home Phone Work Phone Cell Phone
Email Address
Social Security Number: No Yes If yes: __________________________________________
Tax I. D. Number: No Yes If yes: __________________________________________
Date of Birth
If victim is deceased, date of death
Please indicate the type of crimes:
Police Report Number (if known)
State Zip County
Alleged Suspect’s First Name (if known)
Relationship of suspect to victim (if any)
Has the suspect been arrested?
No
Unknown
Have charges been filed?
No Yes Unknown
Cause Number (if known)
Brief Description of Crime
Brief Description of Injuries (if any)
If this is a family violence crime, have you obtained a permanent protective order? No
Yes
If this is a family violence crime, are there any prior incidents reported to law enforcement
No
Yes
Adult Sexual Assault
Child Sexual Assault
Family Violence
Child Physical Abuse/Neglect
Robbery
Assault (Non-family)
Alleged Suspect’s Last Name (if known)
Date of Crime
Law Enforcement Agency (e.g. police, sheriff)
Location of Crime: Street Address
City
Yes
Gender
Male
Female
Aggravated Assault
DWI/Vehicular Crime
Child Pornography
Human Trafficking
Elder Abuse
Homicide
Kidnapping
Stalking
Other
SECTION 2 - CRIME INFORMATION: You must complete this section or your application cannot be processed.
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If this is a sexual assault, was a forensic medical exam performed?
No Yes Date of forensic medical exam:
Are you seeking reimbursement ONLY for expenses incurred in connection with emergency medical treatment received at the time of the
sexual assault forensic medical exam? No Yes
If yes, you need only complete SECTION 4 (MEDICAL), SECTION 17 (APPLICATION ASSISTANCE), and the ACKNOWLEDGEMENT AND
AUTHORIZATION to finalize this application. By checking "Yes" above, you indicate that you are not applying for additional CVC awards such as
counseling expenses, ongoing medical expenses, rent/relocation and loss of earnings. You have three years from the date of the crime to request
additional awards.
SECTION 2a-CRIME INFORMATION: FORENSIC MEDICAL EXAM
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SECTION 3-CLAIMANT INFORMATION: The claimant is a person, other than the victim, who has out of pocket expenses as a direct result
of the crime, is an immediate family member(s) of the victim who requires Psychiatric Care/Counseling as a result of the crime or
is
someone who has legal authority to act on behalf of the victim. CVC cannot discuss a claim with anyone who is not listed as a
claimant. If there are additional claimants, please list them on a separate sheet of paper and include all the required information.
Claimant 1
First Name Middle Name Last Name
Mailing Address City State Zip
Home Phone Work Phone Cell Phone
Email Address
Social Security Number: No Yes
If yes: __________________________________________
Tax I. D. Number:
No
Yes
If yes: __________________________________________
Gender
Male
Female
Date of Birth Relationship to Victim
Claimant 2
First Name Middle Name Last Name
Mailing Address City State Zip
Home Phone Work Phone Cell Phone
Email Address
Social Security Number:
No
Yes
If yes: __________________________________________
Tax I. D. Number:
No
Yes
If yes: __________________________________________
Gender Male Female
Date of Birth Relationship to Victim
Claimant 3
First Name Middle Name Last Name
Mailing Address City State Zip
Home Phone Work Phone Cell Phone
Email Address
Social Security Number:
No
Yes
If yes: __________________________________________
Tax I. D. Number: No Yes
If yes: __________________________________________
Gender
Male Female
Date of Birth Relationship to Victim
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SECTION 4-MEDICAL: Reasonable and necessary health care for the victim as a direct result of
the crime. Medical insurance and benefit
plan MUST meet their legal obligation to pay crime-related expenses.
VICTIM TREATMENT INFORMATION
Did the victim require medical treatment at the time of the crime? No Yes
1. Name of first treating hospital/clinic/doctor:
Address City State Zip
Phone Number Fax Number
Did victim require additional medical treatment upon release from the hospital or clinic or
did the victim
seek any other medical treatment?
No
Yes
2. Name of health care provider who treated crime-related injuries:
Address City State Zip
Phone Number Fax Number
3. Name of health care provider who treated crime-related injuries:
Address City State Zip
Phone Number Fax Number
VICTIM DISABILITY INFORMATION
Was the victim a person with
disability?
No
Yes
If yes, date of disability
Was the disability:
Physical
Mental
Both
If yes, describe
Does the victim have a new
disability due to the crime?
No
Yes
If yes, describe
VICTIM INSURANCE INFORMATION
Did the victim have health insurance or a benefit plan to cover medical expenses at the time of the crime?
Does the victim have health insurance or a benefit plan to cover medical expenses on the date of application?
No Yes
Name of Medical Insurance Company/Benefit Plan
No Yes
Has an application been f
iled with M
edicaid
or
M
edicare since
the
crime?
No
Yes
If there are crime-related dental injuries,
does the victim have dental insurance?
No
Yes
If yes, name of victim’s Dental Insurance Company
No Yes
Was the victim the driver of auto?
No
Unknown
If yes, does he/she have auto insurance?
No
Name of victim’s auto insurance
Did the owner of the auto involved in
the crime have auto insurance?
No
Yes
Unknown
If yes, name of owner’s auto insurance
Was the suspect the driver of auto?
Unknown
If yes, does he/she have auto insurance?
Name of suspect’s auto insurance
Is there additional assistance available to victim from:
Workers’ Compensation
Disability Insurance
Social Security Assistance Veterans’ Benefits
Other ___________________________________
Has an insurance claim or any request for additional assistance related to this crime been filed? No Yes
Yes
Yes
Unknown
No
Yes
No
Yes
Unknown
Does the victim have Medicare?
If Yes, what type of Medicare?
A
B
C
D
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Page 6 of 9
SECTION 5-PSYCHIATRIC CARE/COUNSELING: Available to victim and/or certain claimants. Please indicate who has received or
will be receiving psychiatric care/counseling because of the crime.
Name
Medical/Mental Health Insurance
No Yes
ame If y es, n
of Insurance Company
Name
Medical/Mental Health Insurance
No Yes
ame If y es, n
of Insurance Company
Name
Medical/Mental Health Insurance
No Yes
ame If y es, n
of Insurance Company
SECTION 6-LOSS OF EARNINGS: Includes reimbursement of earnings lost as a result of medical treatment or participation in, or
attendance at, the investigation, prosecutorial and judicial processes. Your employer will be contacted by CVC.
Victim Employment Information
Is the victim seeking loss of earnings?
No
Yes
Was the victim employed on the date of crime?
No
Yes
Employer’s Name
Phone Fax Victim’s Occupation/Job Title
Address City State Zip
Was the victim self-employed on
the date of the crime?
No
Did the crime occur while the victim was on
the job?
Last Date Worked Date Returned to Work
Claimant Employment Information
Name of claimant seeking loss of earnings. If there are additional claimants, please list them on a separate sheet of paper and include all
required information.
Is the claimant self-employed?
No Yes
SECTION 7-LOSS OF SUPPORT: Available to dependents of the victim who have lost support as a result of the crime. All dependents
must be listed as claimants in this application.
Name(s)
SECTION 8-RELOCATION: Available to a victim of family violence, a victim of sexual assault who is assaulted in the victim’s residence, a
victim of stalking or a victim of human trafficking. Please indicate adult household members of the victim at the time of the crime.
List the names of all adult household members:
SECTION 9-FUNERAL: Includes funeral and burial expenses incurred as a result of the crime. Please attach a copy of the funeral and
burial contract(s), (if available).
Funeral Home name
Phone
Fax Contact
SECTION 10-CRIME-RELATED TRAVEL: Includes travel exceeding 20 miles one way for participation and attendance at funeral services,
medical appointments including psychiatric care/counseling and criminal justice proceedings. This is applicable to victim or claimant(s). Please
list the victim or claimant(s) requesting travel.
Name(S)
Yes
No
Yes
Employer's Name
Phone Fax Claimant's Occupation/Job Title
Address
City
State
Zip
Claimant Name:
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Page 7 of 9
SECTION 11-CRIME SCENE CLEAN-UP: Includes professional cleaning services for crime scene clean-up. Does not include repair or
replacement of damaged property. Submit itemized bill from professional cleaning company, (if available).
Do you have homeowners/renters insurance?
No
If yes, what is the name of the Homeowners/Renters Insurance
Company?
SECTION 12-MINOR CHILD OR DEPENDENT CARE: Available for child or dependent care that is a new expense as a result of the crime.
Care must be provided by a licensed care provider.
Is child care or dependent care a new expense?
No Yes
Item:
SECTION 13-REPLACEMENT OF PROPERTY SEIZED: Available for clothing, bedding, or property seized by law enforcement as evidence
or rendered unusable by the criminal investigation. This does NOT cover damaged or stolen property.
Value $
Item:
Value $
Black/African American
What is the victim’s national origin (country of birth)?
Where did you find out about the Crime Victims’ Compensation Program?
Advocacy Group
Internet
SECTION 15-ATTORNEY INFORMATION: This section refers to representation by an attorney who assisted the victim or claimant in filing
for Crime Victims’ Compensation or in pursuing a civil legal action for monetary damages. This DOES NOT include attorney representation
for child custody, divorce, immigration proceedings or for criminal prosecution (District/County Attorney’s Office.)
Has an attorney been hired or retained to: Help the victim/claimant complete this Crime Victims’ Compensation application?
No
Has an attorney been hired or retained to: Represent the victim’s or claimant’s interests in pursuing civil legal action against the
suspect/offender or in an insurance claim related to this crime?
No
Attorney’s Last Name Attorney’s First Name Phone Number Fax Number
Mailing Address City State Zip
SECTION 16-LAWSUIT OR OTHER SETTLEMENT INFORMATION
Is the victim or claimant a party to a lawsuit or insurance or other type of settlement related to this crime?
No
Has the victim or claimant received insurance or any other type of third party settlement funds related to this crime?
SECTION 17-APPLICATION ASSISTANCE
Did someone help you complete this application? No
Yes
Last Name First Name
Title
Agency/Organization
Mailing Address City State Zip
E-Mail Address
Phone Number
Fax Number
Yes
Unknown
SECTION 14-DEPARTMENT OF JUSTICE INFORMATION: The following voluntary information is used for statistical purposes only to comply
with the federal regulations.
Item:
Value $
Item:
Value $
To which ethnic group does the victim belong?
American Indian/Alaskan Native
Asian
Hispanic/Latino
Public Service Announcement
CVC Staff
Brochure
Hospital
Victim Assistance Program
Poster
Other
Yes
If yes, please attach a letter of representation.
Yes
If yes, please attach a letter of representation.
Yes
Unknown
No
Yes
Unknown
Other Race
Native Hawaiian and Other Pacific Islander
Multliple Races
10/15
Page 8 of 9
Law Enforcement
White Non-Latino/Caucasian
Acknowledgement and Authorization
This authorization is part of your application and must be completed and signed in order to process this application.
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TEXAS CRIME VICTIMS COMPENSATION PROGRAM APPLICATION

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