10/15 Page 1 of 9 TEXAS CRIME VI COMPENSATION PROGRAM APPLICATION Nota: Si tiene alguna pregunta sobre esta solicitud o si la desea en espanol, favor de llamar alPrograma deCompensacin para las Victimas de Crimen al (512) 936-1200 o (800) 983-9933. Please read the directions on this page before completing the application. Reading these instructions will help youcompleteeach section correctly. Include all the documentation you can. If you have a copy of the police report, protective order with affidavit, hospital ordoctorbills, health insurance card, or auto insurance declaration page (if the crime is auto-related), be sure to sendthem with theapplication. If you require additional space on any section of the application, please attach a separate sheet of paper and includealltherequired information. If you do not have this documentation, do not wait to mail the application. Send the application as soon as you havecompletedit. Collect all additional information so that you will have it when we contact you. Keep this page so that you will have our address and phone number. Mail your completed application to:Office of the Attorney General Crime Victims' Compensation Program (011) P.O. Box 12198 Austin, Texas 78711-2198 If your address or phone number changes, it is important that you let us know. The toll-free number for victims,claimants and service providers is (800) 983-9933. Austin callers should use (512) 936-1200. For security reasons,the Crime Victims' If you need help completing this application, contact your local law enforcement agency's Crime Victim Liaison oryour local District Attorney's Victim Assistance Coordinator. The Crime Victims' Compensation staff is also availableto help by phone, or you may access our website at www.texasattorneygeneral.gov to find more information on theprogram. GENERAL INFORMATION What is the Crime Victims' Compensation (CVC) Program? The CVC Program may provide financial assistance to victims of violent crime for related expenses that cannot bereimbursed by insurance or other sources. The Program is administered by the Office of the Attorney General and is committed to assisting victims andclaimants who qualify. The information provided is meant to be generally informative, and the statutory requirementsof the Texas Crime Victims' Compensation Act (Texas Code of Criminal Procedure, Chapter 56) and the rules setforth in Title 1 of the Texas Administrative Code, Part 3, Chapter 61, govern the Program.Money in the Victims of Crime Compensation Fund comes from fees paid by those convicted of a crime. Keep this page for your records. American LegalNet, Inc. www.FormsWorkFlow.com 10/15 Page 2 of 9 What are the basic eligibility requirements for Crime Victims' Compensation Program benefits? The victim must be a resident of Texas, a United States resident who is victimized while in Texas, a Texas residentvictimized in another state or country that does not have a crime victim compensation fund, or certain other individuals. The crime must be reported to the appropriate state or local public safety/law enforcement agency within a reasonableperiod of time. The victim or claimant must cooperate with law enforcement officials in the investigation and prosecution of the case. NOTE: If a Medical Forensic Sexual Assault Exam was conducted on or after September 1, 2015, payments for emergency medical care received at the same time as the exam may be available even when a victim does not report the crime or meet certain other eligibility requirements. For more information, please visit the Crime Victim Compensation web page or call (800) 983-9933. Who may be eligible for Crime Victims' Compensation Program benefits? Victims of violent crime who suffer physical or mental harm as a direct result of the crime.A victim's dependents, family or household members who qualify as claimants under the law.Someone authorized by the victim to act on his or her behalf. Who is not eligible for Crime Victims' Compensation Program benefits? The offender, an accomplice of the offender or any person engaged in illegal activity at the time of the crime.Anyone injured as a result of a motor vehicle accident, except under certain circumstances provided by law.Benefits may be denied or reduced if the victim's or claimant's own behavior contributed to the crime.Anyone incarcerated when the crime occurred. Any victim or claimant who knowingly or intentionally submits, or causes to be submitted, false or forged information to theCrime Victim Compensation Program. What expenses may be covered with Crime Victims' Compensation Program benefits? Reasonable and necessary medical and funeral expenses.Travel exceeding 20 miles one way for participation and attendance at funeral services, medical appointments and criminaljustice appointment.Loss of earnings as a result of the disability of the victim.Loss of earnings for investigative, judicial or medical appointments.Loss of support to dependents of victim's, as a result of the victim's death or if the victim was supporting them at the time ofthe crime.Psychiatric care/counseling.Counseling for the victim and eligible claimants.Eyeglasses, hearing aids, dentures or prosthetic devices, if damaged during or needed as a result of the crime.Crime scene clean-up.Replacement of property seized as evidence or rendered unusable by the investigation.New expenses for child or adult dependent care as a result of the crime. One time rent and relocation expenses for victims of family violencevictims of sexual assault Reasonable attorney fees for assistance in filing the Crime Victims' Compensation Program application. What expenses are not covered by Crime Victims' Compensation Program benefits? Damage, repair or loss to property or vehicle.Pain, suffering or emotional distress damages.Any expense which is not the direct result of the crime. Who is the payor of last resort? All other available third party resources (for example, Medicare, Medicaid, personal health insurance, workers'compensation and settlements) must meet their legal obligations to pay crime-related expenses. The Crime Victims' Compensation Program must be notified before a civil lawsuit is filed in relation to the crime, ifrestitution is ordered by the criminal court, or if any party receives the proceeds of a settlement. CVC is considered the payor of last resort. Keep this page for your records. American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com SECTION 5-PSYCHIATRIC CARE/COUNSELING: Available to victim and/or certain claimants. Please indicate who has received or will be receiving psychiatric care/counseling because of the crime. NameMedical/MentalHealthInsuranceNo Yes ame If y es, n of Insurance Company NameMedical/MentalHealthInsuranceNo Yes ame If y es, n of Insurance Company NameMedical/MentalHealthInsuranceNo Yes ame If y es, n of Insurance Company American LegalNet, Inc. www.FormsWorkFlow.com SECTION 6-LOSS OF EARNINGS: Includes reimbursement of earnings lost as a result of medical treatment or participation in, or attendance at, the investigation, prosecutorial and judicial processes. Your employer will be contacted by CVC. Victim Employment Information Is the victim seeking loss of earnings? No Yes Was the victim employed on the date of crime? No Yes Employer222s Name Phone Fax Victim222s Occupation/Job Title Address City State Zip Was the victim self-employed on the date of the crime? No Did the crime occur while the victim was on the job? Last Date Worked Date Returned to Work Claimant Employment Information Name of claimant seeking loss of earnings. If there are additional claimants, please list them on a separate sheet of paper and include all required information. Is the claimant self-employed? No Yes SECTION 7-LOSS OF SUPPORT: Available to dependents of the victim who have lost support as a result of the crime. All dependents must be listed as claimants in this application. Name(s) SECTION 8-RELOCATION: Available to a victim of family violencea victim of sexual assault who is assaulted in the vi