Date : To: From: The purpose of this correspondence is to inform you that the Criminal Justice Coordinating Council (CJCC) is nt victims of a violent crime. In order to administer these funds, the CJCC is required, pursuant to O.C.G.A. 24717 - 15 - 6, to thoroughly investigate each complete claim. Recently, a crime victim who was victimized in your jurisdiction submitted a claim. Instructions : Please answer the follo wing questions to assist us in determining whether the listed victim is an innocent victim of a violent crime. Please fax this questionnaire to (404) 463 - 7652 or forward it to the address listed above within 15 business days of receipt. If you should hav e any questions regarding this questionnaire or the Georgia Crime Victims Compensation Program, please call (404) 657 - 2222 or 1 - 800 - 547 - 0060. CJCC Information Prosecuting Attorney Information Claim Number : Date of Offense : Victim : Alleged Offender(s) : Claimant : Case Number : Officer : Badge # : 1. Do you have a criminal case in your office? Yes No If NO , please sign and return as indicated in the instructions above. 2. If you answered yes to Question 1 , was a crime committed? Yes No Unknown 3 . Di If YES , please explain. Yes No Unknown 4 . Has anyone been indicted ? Yes No Unknown If YES , please list indictment and date. Indictment: Date: // 5 . Has the case gone to trial? Yes No Unknown If YES , please indicate if restitution has been sought. Name and Title: (print): Signature: Date: // Telephone No.: .. Ext.: American LegalNet, Inc. www.FormsWorkFlow.com