SUPERIOR COURT OF THE DISTRICT OF COLUMBIA CRIME VICTIMS COMPENSATION PROGRAM 515 Fifth Street, N.W., Suite 109 Washington, D.C. 20001 APPLICATION FOR CRIME VICTIMS COMPENSATION DATE RECEIVED: _______________________________ CLAIM NUMBER: _______________________________ INSTRUCTIONS 1. 2. 3. Please type or print clearly in ink. If you need more space, attach additional sheets. If you need assistance completing the form, call (202) 879-4216 or come to the Crime Victims Compensation Program at the address listed above. Attach all medical, hospital, and/or funeral bills and submit them with your application. This will help the processing of your application. The Claimant must sign the application. If the Claimant is under 18 years of age, the application must be signed by the parent or guardian. DO NOT INCLUDE costs for lost or damaged property or for pain and suffering. They are not covered by D.C. Law. 7. If you do not know the answer to a question, please write "unknown" in the space provided. 8. Please sign the Authorization For Release of Information. 9. Submitting information that you know is false, or withholding important information is a crime and may result in a fine, and/or imprisonment and forfeiture of compensation. 10. The total maximum that can be paid in a claim is $25,000. There are sub-limits for certain expenses. 11. The crime must have occurred in the District of Columbia. 6. 4. 5. This is an application for: Loss of Earnings Loss of Support Loss of Services Medical/Dental Expenses Funeral Expenses Transportation to Receive Services Mental Health Services Crime Scene Clean-up Replacement Value of Clothing Kept as Evidence (No reimbursement when victim is deceased) Temporary Emergency Housing or Moving Expenses for Victims in Immediate Danger Home Security ____________________________________________ SECTION 1 ­ VICTIM/CLAIMANT INFORMATION (A separate application needs to be completed for each victim) VICTIM'S NAME (The victim is the person injured as a result of a crime.) Street Address (Mailing Address) Home Telephone Number Date of Birth City Work Telephone Number Social Security Number State Zip Code Ward Additional Means to Contact Victim/Cell Phone/Family Member CLAIMANT'S NAME (Person filing application for deceased, incapacitated or minor victim) Street Address (Mailing Address) Home Telephone Number Date of Birth City State Zip Code Ward Work Telephone Number/additional contact information Social Security Number Form CV-2044A/ Mar. 06 Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com The following information concerning the victim is used for statistical purposes only. The victim is/was: Disabled: Yes No Gender: Male Female Primary Language: English Spanish Other _________________ (Please Specify Race: Black White Hispanic/Latino Native American/Alaskan Asian/Pacific Islander Other _________________ (Please Specify) Who referred you to the compensation program? Law Enforcement Agency U.S. Attorney's Office Department of Justice Hospital Media (TV, Radio, etc.) Domestic Violence Intake Center Other:______________________ (Please Specify) SECTION 2 ­ CRIME INFORMATION Type of Crime (please check one) Arson Assault Sexual Abuse Cruelty to Children Burglary Date of Crime Police Complaint Number Date Crime Reported Domestic Abuse Kidnapping Robbery Reckless Driving Threats Homicide Car jacking Drunk Driving Stalking Unlawful Use of Explosives Agency to Which Crime Was Reported Officer's Name In cases of domestic abuse, please indicate Civil Protection Order number (if applicable) In cases of sexual assault, medical treatment facility name (if applicable) In cases of child cruelty, please indicate the neglect petition case number Name of offender(s) Did victim know offender(s)? YES NO, If YES, in what way? ____________________________________________________ Brief description of crime and injuries;________________________________________________________________________________ _______________________________________________________________________________________________________________ Location of Crime (Street Address) City State 16. Country NOTE: If crime did not occur in the District of Columbia, you must file a claim for compensation in the state where the crime occurred. SECTION 3 ­ MEDICAL/DENTAL/MENTAL HEALTH INFORMATION (LIMITS: MENTAL HEALTH-Adult $3,000, minor $6,000. No sub-limit on medical and dental treatment, but total combined may not exceed $25,000.) Did you receive medical/dental/or mental health treatment? Name of Physician, Hospital or Other Provider of Service Address a. b. PLEASE SUBMIT COPIES OF ALL AVAILABLE BILLS RECEIVED TO DATE. PLEASE ATTACH ALL INSURANCE PAYMENT STATEMENTS AND REJECTIONS. American LegalNet, Inc. www.FormsWorkFlow.com Yes City/State/Zip No Phone Number Amount of Bill CV-2044B/ Mar. 06 Page 2 of 6 SECTION 4 ­ FUNERAL EXPENSES (Funeral Limit $6,000) Name of Funeral Home/Phone No: Name of Cemetery/Phone No: (Please attach a copy of the funeral bill) (Please attach a copy of cemetery bill) YES NO Total Amount of Funeral/Cemetery Bill: $ ________________Have the Funeral/Cemetery expenses been paid? If YES, by whom? ________________________________________________________________________________________________ (Please submit receipt) SECTION 5 ­ LOSS OF SUPPORT FOR SURVIVORS OF HOMICIDE (Limit $2,500 per dependent, no more than $7,500 per claim) YES NO Have you submitted a claim to the Social Security Administration? Did the victim have dependent(s)? NO Did the victim provide support? YES (list dependents on section 8 of this application) YES (submit evidence of employment and/or child support) NO SECTION 6 ­ LOSS OF SERVICES AND EXPENSES FOR SUBSTITUTE SERVICES (Limit $250.00 per week, not to exceed $2,500) Please list all services such as child care and housekeeping that are no longer provided by the victim as a direct result of the violent crime. Expenses Incurred 1. _____________________________________________________________ 2. _____________________________________________________________ $ _______________ $ _______________ SECTION 7 ­ LOSS OF WAGES (Limit: 80% of net pay, up to $10,000 or 1 year, whichever is reached first) Were you employed at the time of the crime? Yes Name No Supervisor Victim's Employer (at time of crime) _______________________________________________ _______________________________ ____________________________________________________________________________________________________