COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : State of Idaho Crime Victims Compensation Idaho Industrial Commission P.O. Box 83720 Boise, ID 83720-0041 (208) 334-6080 : CRIME VICTIM'S : Plaintiff(s) APPLICATION FOR COMPENSATION : -against- Index No. Calendar No. JUDICIAL SUBPOENA : FAMILY ASSISTANCE APPLICATION Print or type -- Then mail to the address above. Name of Family Member Seeking Benefits : Defendant(s) : ...................................................... City Address Date of Birth Telephone Marital Status Social Security # State Zip Sex Relationship to Primary Victim Name of Primary Victim Date of Crime County Where Crime Occurred GREETINGS: Was a claim filed for Crime Victims benefits on the primary victim? Yes No THE PEOPLE OF THE STATE OF NEW YORK TO Type of crime: Homicide Sexually abused minor Date filed: Sexual assault (adult only) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Name of your mental health counselor , the Honorable at the Court If none, do you need a referral? located at County of No Yes in room , on the day of , 20 , at o'clock in the noon, and at any recessed Addressor adjourned date, to testify and give evidence as a witness in this action on the part of the of mental health counselor: Date treatment began: Check other sources which failure available to pay for your counseling: Your may be to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a a. Medical Insurance e. Employee Assistance Program b. Medicare f. Other (Explain) result of your failure to comply. c. Medicaid g. None d. Veteran's Benefits (If any of the above resources are checked, give company name, address and policy numbers Witness, Honorable below:) Court in County, day of CVCP USE ONLY , one of the Justices of the , 20 (If Medicaid/Medicare is checked, please list dates you applied for benefits:) YOU MUST USE COLLATERAL SOURCES SUCH AS MEDICAL INSURANCE POLICIES AND (Attorney must sign above and type name below) GOVERNMENT BENEFITS SUCH AS MEDICAID BEFORE YOU CAN RECEIVE CRIME VICTIMS FUNDS. The filing of this claim form is authorization for the release of any medical/counseling records to the Crime Victims Compensation Program from the date of the crime. Attorney(s) for Signature Date I declare under penalty of perjury that the foregoing information is true and complete. Signature of legal guardian Office and (Required if secondary victim is a minor) CVCP USE ONLY CV-02 (9/00) P.O. Address Date CLAIM NUMBER Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com