CRIME DISCLOSURE JD-VS-35 Rev. 12-18 C.G.S. 247 54-209(d) and (e)STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov/crimevictim/Instructions 1. Print or type the information requested. 2. Please send to: Office of Victim Services, 225 Spring Street, 4th Floor, Wethersfield, CT, 06109 or Fax to: 860-263-2780 or e-mail to: OVSCompensation@jud.ct.gov. Name of victim (first, middle, last) Date of birth (mm/dd/yyyy)1. Did the victim disclose that she or he was a victim of a crime in Connecticut?6. Date of incident:7. Check your profession: To be eligible for victim compensation, victims must report the crime to police; however, state law allows victims of certain crimes to disclose the crime to 1 of the professionals listed below instead of reporting to police. Victims of domestic violence may only disclose to a certified sexual assault counselor or a certified domestic violence counselor instead of reporting to police. Date incident disclosed to you: No (skip to question 7) alcohol and drug counselor nurse (advanced practice, practical, or registered) clinical social worker physician or physician assistant counselor police officer emergency medical services provider psychologist employee of Department of Children and Families resident physician or intern at a Connecticut hospital marriage and family therapist sexual assault or domestic violence counselor (must be certified) mental health professional surgeon Name of the person completing form (print first, middle, last) Provider license number, if applicable Agency address, city, state zip Name of agency Telephone number Title Signature of person completing form DateThank you for helping OVS in its efforts to provide financial compensation to eligible crime victims. ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, call OVS at 1-800-822-8428. Name of claimant or person filing for claimant Claim number Claims examiner Yes (go to question 2) school guidance counselor school principal school teacher5. Describe the incident and any physical or emotional injuries:2. Check the type of crime (you may check more than 1 box):3. Did the victim suffer a physical injury? sexual assault human trafficking domestic violence child abuse other: Yes No 4. Did the victim suffer an emotional injury from a threat of either physical injury or death and received treatment? Don't know Don't know No YesCity/town of incident: American LegalNet, Inc. www.FormsWorkFlow.com