I certify that the information in this application for victim compensation is true to the best of my knowledge, information, en-USand belief. I give permission to any hospital, physician(s) or other person(s) who attended, examined, or gave services to me en-USor to any minor child or incapacitated adult for whom I am the parent, legal guardian, or conservator and have the authority en-USto act on his or her behalf; to my employer(s) and the employer(s) of the person I am acting on behalf of; any police or other en-USmunicipal authority or agency, or public authorities including state and federal revenue services, any insurance company or en-USen-USall information regarding the incident leading to the victim222s death and this application for victim compensation. A copy of en-USthis authorization will be considered as effective and valid as the original.en-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USI also understand that my providers may be reimbursed directly for debts that I owe. þ þ en-USThe adult applicant, the parent/legal guardian/conservator of a minor child (under 18 years old), or the legal guardian/conservator for an en-USincapacitated adult must sign this application. Applications that are not signed will be returned.en-USPlease mail, fax, or email the completed application to:en-USen-USen-USContact OVS at:en-USen-USSECTION 11 226 en-USSTATEMENT OF FACTS AND AUTHORIZATION SURVIVOR BENEFITS en-USAPPLICATION en-USen-USSECTION 1 226en-US VICTIM INFORMATION SECTION 2 226 en-USCLAIMANT INFORMATION en-USen-USen-USit is important that you tell us if your contact information changes. If we cannot reach you, you may miss important en-USdeadlines set by state law or your claim may be closed.en-USThe person who has expenses because of the crime. en-USHow is the claimant related to the victim?en en-USen-US child en-USen-US spouse en-USen-US parent en-USen-US grandchild en-USen-US grandparent en-USen-US spouse222s parent en-USen-US stepparent en-USen-US brother en-USen-US sister en-USen-USen-USen-USen-USen-USen-USen-US adopted child en-USen-US party to a civil union en-USen-US aunt en-USen-US uncle en-USen-US niece en-USen-US nephew en-USen-US other þ þ þ þ þ þ en-USen-USen-US female en-USen-US male en-USen-US other þ þ þ þ þ þ þ þ Primary language spoken þ en-USen-USen-US female en-USen-US male en-USen-US other SECTION 10 226 en-USCRIME-RELATED EXPENSES AND FINANCIAL RESOURCES en-US(continued)en-US þ þ en-USADA NOTICEen-USen-US en-USen-US en-USen-USen-USen-USand alarm systems. Provider Name þ Address en-US(street, city, state, zip) þ Telephone þ þ þ þ Financial Resources þ Insurance Company þ Policy Number þ Telephone en-US Homeowners222 Insurance þ en-US þ en-USen-US þ (for crimes involving vehicles) en-USen-US en-USEXPENSES TO ATTEND ADULT COURT PROCEEDINGSen-USen-US en-USen-US en-USparents, grandchild, grandparent, stepparent, brother and sister (natural and half), aunt, uncle, niece, and nephew.en-USen-USen-US travel expenses (includes mileage reimbursement)en-US þ en-USen-US Name of employer þ Contact name þ Telephone þ þ þ þ þ þ en-USen-US en-USLOSS OF SUPPORTen-USen-US þ þ þ þ þ þ þ þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com en-US te of crime þ Address and city where crime happened en-USen-USen-US homicide en-USen-USen-USen-US evading (hit and run) en-USen-US þ en-USen-USas someone arrested for the crime ? þ en-USen-US en-USyes en-USen-US en-USno en-USen-US en-USdon222t know Name of person arrested, if known en-US en-USyes en-US en-USno en-US don222t know If yes, city where courthouse is located þ en-USen-USen-USen-USyesen-USen-USnoen-USen-USdon222t know en-USSECTION 4 226 en-USATTORNEY Ren-USEPRESENTATION SECTION 3 226 en-USPARENT/LEGAL GUARDIAN/CONSERVATOR INFORMATION en-USincapacitated adult. þ þ þ þ þ þ þ þ en-USSECTION 6 226 en-USSTATISTICAL INFORMATIONen-USen-UShelping you with your claim, a civil lawsuit, or both and provide the attorney222s contact information.en-USen-USen-USen-US en-USen-USen-US en-US asian en-US en-US en-USen-US en-US en-US en-USother raceen-USen-USen-US yes en-USen-US no en-USen-US don222t know en-US en-USSECTION 7 226 en-USCRIME INFORMATION en-USSECTION 8 226 en-USOFFENDER INFORMATION en-USSECTION 5 226 en-USPERMISSION TO CONTACT OR SPEAK WITH ANOTHER PERSON þ þ þ þ þ þ þ en-USen-USparent en-USen-US adoptive parenten-USen-USlegal guardian en-USen-US conservatoren-USen-USen-USsomeone about your claim, or both, and provide that person222s contact information. en-USen-USen-USen-US Permission to speak with about my claimen-US þ þ þ þ þ þ þ Primary language spoken þ en-USen-USen-US female en-USen-US male en-USen-US other en-USSECTION 9 226 en-USCRIMES INVOLVING A VEHICLEen-USen-USen-USen-USen-US en-USen-USthe other driver222s insurance en-USen-USa relative222s insurance en-USen-USmy employer222s insuranceen-USen-USen-USen-US en-USen-US yesen-US en-USen-US noen-US en-USen-US settlement pendingen-US Insurance company name þ Address (street, city, state, zip) þ þ þ en-USen-USthe place of business or person that served the alcohol?en-US en-USen-US yesen-US en-USen-US noen-US en-USen-US don222t know SECTION 10 226 en-USCRIME-RELATED EXPENSES AND FINANCIAL RESOURCESen-USen-USen-USen-USen-USen-USPlease also include copies of receipts showing your payments or an itemized bill from the funeral home.en-US en-USen-US en-USen-USen-US en-USen-US yesen-US en-USen-US noen-US en-USen-US don222t knowen-USIf you checked yes above, are you the administrator or the executor of the estate? en-USen-USyes (please attach a copy of the probate court222s appointment order) en-USen-USno (please apply to the estate for reimbursement of funeral expenses) Name of funeral home Contact name þ Telephone þ þ þ Financial Resources þ Insurance Company þ Member Number þ Telephone en-US en-USen-US (funeral) en-USen-US (for crimes involving vehicles) en-USen-US (for crimes at work) en-USen-USen-USen-US en-USMEDICAL, MENTAL HEALTH, DENTAL AND PRESCRIPTION EXPENSESen-USen-US Provider Name þ Address en-US(street, city, state, zip) Telephone Financial Resources þ Insurance Company þ Member Number þ Telephone en-US en-USen-US þ en-USen-USHealth Insurance en-US(primary) en-USen-USHealth Insurance en-US(secondary) en-US en-USen-US þ en-USen-US (for crimes involving vehicles) þ en-US en-USen-US (for crimes at work) þ en-USen-USen-US American LegalNet, Inc. www.FormsWorkFlow.com en-US te of crime þ Address and city where crime happened en-USen-USen-US homicide en-USen-USen-USen-US evading (hit and run) en-USen-US þ þ en-USen-USas someone arrested for the crime ? þ en-USen-US en-USyes en-USen-US en-USno en-USen-US en-USdon222t know þ þ Name of person arrested, if known en þ en-USen-US en-USyesen-US en-USen-US en-USnoen-US en-USen-US don222t know þ þ If yes, city where courthouse is located þ en-USen-USen-USen-US yes en-USen-US no en-USen-US don222t know en-USSECTION 4 226 en-USATTORNEY Ren-USEPRESENTATION SECTION 3 226 en-USPARENT/LEGAL GUARDIAN/CONSERVATOR INFORMATION en-USincapacitated adult. þ þ þ þ þ þ þ þ en-USSECTION 6 226 en-USSTATISTICAL INFORMATIONen-USen-UShelping you with your claim, a civil lawsuit, or both and provide the attorney222s contact information.en-USen-USen-USen-US en-USen-USen-USen-US þ en-USen-US asian þ en-USen-US þ en-USen-US en-USen-USen-US þ en-USen-US þ en-USen-US en-USother race en-USen-USen-US yes en-USen-US no en-USen-US don222t know en-US en-USSECTION 7 226 en-USCRIME INFORMATION en-USSECTION 8 226 en-USOFFENDER INFORMATION en-USSECTION 5 226 en-USPERMISSION TO CONTACT OR SPEAK WITH ANOTHER PERSON þ þ þ þ þ þ þ en-USen-US parent en-USen-US adoptive parenten-USen-US legal guardian en-USen-US conservatoren-USen-USen-USsomeone about your claim, or both, and provide that person222s contact information. en-USen-USen-USen-US Permission to speak with about my claimen-US þ þ þ þ þ þ þ Primary language spoken þ en-USen-USen-US female en-USen-US male en-USen-US other en-USSECTION 9 226 en-USCRIMES INVOLVING A VEHICLEen-USen-USen-USen-USen-USen-US en-USen-US the other driver222s insuranceen-US en-USen-US a relative222s insuranceen-US en-USen-US my employer222s insurancee