Office of Victims' Services Mailing Address: P Box 1167 .O. Harrisburg, PA 17108-1167 Street Address: 3101 North Front Street Harrisburg, PA 17110 Phone and Fax Numbers: (800) 233-2339 (717) 783-5153 (717) 787-4306 (FAX) Website: www.pacrimevictims.com You may either complete and mail this form to the address listed above or file online at https://www.dave.state.pa.us/daveprod. Victims Compensation Assistance Program Short Form Please read the following before completing this form. You may be eligible for compensation if: �ThecrimeoccurredinPennsylvania. �Thecrimewasreportedtotheproperauthoritieswithin3daysORaProtectionFromAbuseorderwas filedwithin3daysofthecrime. �Youcooperatewithlawenforcementauthoritiesinvestigatingthecrime,thecourts,andtheVictims CompensationAssistancePrograminprocessingtheclaim. �Theclaimisfiledwithin2yearsafterthediscoveryofthecrime(thereareexceptionswhenthevictimisa child). �Youhavepaidoroweatleast$100ofanycombinationoftheexpenseslistedbelow.Ifyouareage60or over,thereisnominimumlossrequirement. You may be awarded compensation for: �MedicalExpenses �CounselingExpenses �LossofEarnings �LossofSupport �RelocationExpenses �FuneralExpenses �Crime-SceneCleanup �TransportationExpenses �Childcare �HomeHealthcareExpenses �StolenCash(Ifyourmainsourceofincomeis SocialSecurityRetirement,DisabilityIncome, SupplementalIncome,SurvivorBenefits, Retirement/Pension(s),DisabilityorCourtOrderedChild/SpousalSupport.) Anoverallmaximumawardshallnotexceed$35,000;however,certainbenefits,suchascounselingand crime-scenecleanup,maybepaidoverandabovethemaximum.Monetarylimitsapplytomostbenefits. The Program does not cover: �Painandsuffering. �Stolenordamagedproperty(exceptreplacementofstolenordamagedmedicalequipment). Aclaimmaybedeterminedineligibleoranawardmaybereducediftheconductofthevictimcontributedto theinjury. (800) 233-2339 HELP FOR VICTIMS OF CRIME IN PENNSYLVANIA www.pacrimevictims.com American LegalNet, Inc. www.FormsWorkFlow.com YourcooperationwiththeProgramandthesubmissionofcompleteandaccurateinformationwillassist usinprocessingyourclaiminatimelymanner. IMPORTANT NOTE:Youdonothavetowaituntilthetrialisoverorallofyourbillsarereceivedtofile aclaim.Youmayfileaclaimifthereisnoknownoffenderorifanarresthasnotbeenmade. General instructions for submitting your claim: �Pleaseprintclearly. �Completeonlythosesectionsthatapplytoyourclaim. �Provideanaccurateaddressandasafephonenumberwhereyoucanbereachedduringtheday. �Provideasmanyoftherequesteddocumentsasyoucanwhenfilingyourclaim.Youmay submityourclaimevenifyoudonothavealltherequireddocuments.TheProgrammayrequest additionalinformationoncetheclaimisreceived. �SigntheAcknowledgement and Reimbursement AgreementandtheAuthorization to Obtain Informationsectionsonthebackoftheclaimform. �IfyouwouldlikeassistanceinfilingyourclaimyoumaycontacttheVictimServiceProgram listedonthebackofthisform.Ifnoagencyislisted,youmaycontacttheVictimsCompensation AssistanceProgramat(800)233-2339forassistance. Please Note: It is important that you inform the Program if you change your address or phone number. To process your claim, we must be able to contact you. TheVictimsCompensationAssistanceProgramisthepayeroflastresort.Thismeansyourawardwillbe reducedbythemoniesyoureceivefromanyothersourceasaresultofthecrime,suchasinsurance, restitution,andcivilsuitsettlements,includingmoniesreceivedforpainandsuffering. We will make every effort to process your claim as quickly and efficiently as possible. Dateclaimmailed____________________________(keepthispageforyourinformation.) (800) 233-2339 HELP FOR VICTIMS OF CRIME IN PENNSYLVANIA www.pacrimevictims.com American LegalNet, Inc. www.FormsWorkFlow.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cutalongthislineandmaintainthisportionforyourrecords.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Victims Compensation Assistance Program Short Form $ Victims Compensation Assistance Program Short Form lMale lFemale (ForOfficialUseOnly)Claim#__________________ Pleasecompletethisentiresectionoftheform.Toprocessyourclaim,wemustbeabletocontactyou. Victim Information Name _________________________________________ DateofBirth_____/_____/_____SS# ________________________ Address_______________________________________ City ___________________State_______ ZipCode_____________ County________________________ SafeDaytimePhone____________________Other Safe Phone __________________ _ Claimant Information If victim is the claimant, write "SAME." If someone other than victim is filing, complete the entire section. Name _________________________________________ DateofBirth_____/_____/_____SS# ________________________ Address_______________________________________ City ___________________State_______ ZipCode_____________ County________________________ SafeDaytimePhone____________________Other Safe Phone __________________ _ lMale lFemale Crime Information DateofCrime_____/_____/_____ DateReportedtoPolice_____/_____/_____ orDatePFAfiled_____/_____/_____ Wasthisacrimeofdomesticviolence?lyeslnoDidthecrimeinvolveamotorvehicle?lyesl no Didthecrimeoccuratwork?lyesl no Locationofcrime(streetnameandnumber) _________________________________________________________________ City______________________________________State_____________County______________________________________ PoliceDepartment___________________________________PoliceIncident#______________________________________ RelationshiptoVictim __________________________ _ Person(s)whocommittedthecrime_______________________________________________________________ Brieflydescribecrimeandinjuries:________________________________________________________________ _______________________________________________________________________________________________ Pleasecompletethesection(s)forthebenefit(s)youareapplyingforandprovideasmuchoftherequested informationthatyoucanatthistime.TheProgrammayrequestadditionalinformationoncetheclaimisreceived. Benefit: Medical/Counseling Expenses Didyouincurmedicalexpenses?lyesl no Didyouincurcounselingexpenses?lyesl no Provide itemized medical or counseling bills. Doyouhaveinsurancetocoveryourmedical/ counselingexpenses?lyesl no Ifyes,provideinsurancebenefitstatementsshowing paymentorrejectionofpaymentforthesebills. Benefit: Loss of Earnings Didyoumissworkandlosepay?lyesl no Datesyoumissedwork____/____/____to____/____/____ Employer'sname,address,andphonenumber: _________________________________________________ _______________