QUESTIONS? Call 1-888-286-7347 or (860) 747-4501 outside Connecticut TDD (860) 747-6597 www.jud.state.ct.us Office of Victim Services, Judicial Branch COMPENSATION FOR CRIME VICTIMS OFFICE OF VICTIM SERVICES Office of Victim Services Claims Unit 31 Cooke Street Plainville, CT 06062 STATE OF CONNECTICUT JUDICIAL BRANCH 31 Cooke Street Plainville, Connecticut 06062 Place Stamp Here JD-VS-10P Rev. 1-03 American LegalNet, Inc. www.USCourtForms.com WHAT IS VICTIM COMPENSATION? The State of Connecticut has a fund to help crime victims with lost wages, medical/counseling expenses; and certain other out-of-pocket costs. Some of the money comes from fees and fines paid by convicted persons. The Office of Victim Services (OVS) runs this and other victim programs. WHEN CAN I APPLY? Up to two years after the injury or death occurs. IS OTHER HELP AVAILABLE? Whether or not you're eligible for compensation OVS offers other programs that include: counseling, information and referral, victim notification, and court-based advocacy. AM I ELIGIBLE? If you answer "yes" to these questions, you may be eligible. Send OVS the self-mailer card or call (888) 286-7347. For more information call: (888) 286-7347 WHAT EXPENSES MAY COMPENSATION COVER? · Medical and dental costs related to the crime · Counseling for victims (and family members in certain cases) · Victim's lost wages · Loss of support and/or funeral costs for family members of homicide victims HOW MUCH CAN BE PAID? · For survivors of homicide: up to $25,000 · For physically injured victims: up to $15,000 HOW DO I APPLY? File an Application for Victim Compensation with OVS. A Claims Examiner will work with you to collect the information needed. I was injured in the course of a crime or injured while helping police during a crime or I am a family member or designated decision maker of a homicide, sexual assault or child abuse victim. I didn't cause the crime or do anything illegal. I reported the crime to police. Other sources don't cover all my eligible costs. Cut along dotted line and mail this card. SEND ME AN APPLICATION FOR COMPENSATION (Please print all items) HOW IS IT PAID? OVS usually reimburses you for lost wages and medical bills you pay, and reimburses the medical provider for any balances after services are provided. CHECK OTHER SOURCES FIRST OVS covers costs that other sources don't cover or only partially cover. Examples of other sources include: · Medicare/Medicaid · Health insurance · Sick time from job · Workers' Compensation · Victim restitution from convicted person · Legal settlements · Disability insurance · Unemployment compensation Full Name I am the : victim parent/legal guardian attorney other Address: No., street, Apt. no. City, state, zip code DO I HAVE TO PROVE FINANCIAL NEED? No, income level is not a criterion. WHO CAN APPLY? The victim, his/her attorney, certain persons who suffer financial loss as the result of a crime, the dependents or designated decision maker of a homicide victim, the parent, legal guardian or other legal representative of a minor or incompetent person. Home telephone no. Work telephone no. American LegalNet, Inc. www.USCourtForms.com