OFFICE OF THE ATTORNEY GENERAL CRIME VICTIM SERVICES DIVISION APPLICATION FOR TEXAS CRIME VICTIMS COMPENSATION

Transcription

1 My office is dedicated to helping victims of crime receive every possible assistance from the Crime Victims Compensation Program. The program helps pay for medical, counseling, funeral, and certain other expenses related to the crime, and we can help you find local resources to personally assist you. You are not alone - we are here to help. John Cornyn, Attorney General of Texas OFFICE OF THE ATTORNEY GENERAL CRIME VICTIM SERVICES DIVISION APPLICATION FOR TEXAS CRIME VICTIMS COMPENSATION COMPLETING THIS APPLICATION i Read through the instructions before you begin to help you complete each section correctly. i Include all the documentation you can - if you have a copy of the police report, hospital or doctor bills, please send them with the application. i If you do not have this documentation, do not wait to mail the application. Send the application as soon as you have it completed and gather the additional information so that you will have it when we contact you. i Keep this front page so that you will have our address and phone number. Mail your completed application to: Office of the Attorney General Crime Victims Compensation (011) P.O. Box Austin, Texas iplease be sure to let us know of any address changes. You can reach us at: Toll free line for victims and family members Austin callers and service providers i If you need help completing the application, contact your law enforcement agency s Crime Victim Liaison or your prosecutor s Victim Assistance Coordinator. The Crime Victims Compensation staff is also available to help. Nota: Si tiene alguna pregunta sobre esta solicitud o si la desea en español, favor de llamar a la División de Compensación para las Víctimas de Crímen al o

2 OFFICE OF THE ATTORNEY GENERAL " STATE OF TEXAS J OHN C ORNYN INFORMATION THE TEXAS CRIME VICTIMS COMPENSATION PROGRAM iprovides financial assistance to victims of violent crime for related expenses that cannot be reimbursed from insurance or other sources. i Is administered by the Office of the Attorney General which is committed to helping victims who qualify under the statutory guidelines of the Texas Crime Victims Compensation Act (Texas Code of Criminal Procedure, Chapter 56). i Money in the Compensation Fund comes from fees paid by those convicted of crime. WHAT ARE THE BASIC CONDITIONS? i The victim must be a resident of Texas, a U.S. resident who is victimized while in Texas, or a Texas resident victimized in another state or country that does not have a compensation program. i The victim must report the crime to law enforcement within a reasonable amount of time so as not to hinder the investigation or prosecution of the offense, unless there is a valid exception. i The victim must cooperate with law enforcement officials in the investigation and prosecution of the case. i Benefits may be denied or reduced if the victim s own behavior contributed to the crime. i All other available sources of reimbursement, including Medicare and Medicaid, personal health insurance, civil suit recovery or settlement, or court ordered restitution to the victim must be used. i The Compensation Program must be notified when a civil lawsuit is filed related to the crime or if restitution is ordered. WHO MAY BE ELIGIBLE? i Victims of violent crime who sustain emotional or physical injury as a direct result of the crime. i Dependents of a victim and immediate family members. i Persons who have a legal responsibility or assume financial responsibility for covered bills or expenses. i Persons who go to the aid of a victim and are injured or killed. WHO IS NOT ELIGIBLE? ithe offender, an accomplice, or person to whom an award would unjustly enrich the offender or accomplice. i Anyone injured in a motor vehicle accident unless the driver intentionally caused the injury, was driving while intoxicated, failed to stop and render aid, or caused the injury or death of the victim due to criminal negligence or manslaughter. i Anyone incarcerated in a penal institution when the crime occurred. i Any victim or claimant providing false or forged information to the Crime Victims Compensation Program. WHAT EXPENSES MAY BE COVERED? i Reasonable medical, hospital, counseling, and funeral expenses. i Loss of earnings or support. i Counseling for immediate family members of the victim. i Reasonable attorney fees for assistance in filing the application and obtaining benefits. i Eyeglasses, hearing aids, dentures, or prosthetic devices if damaged or needed as a result of the crime. i Certain related travel expenses. i Crime scene clean-up. i Property seized as evidence. i Necessary expenses related to child or dependent care. i One-time relocation expenses for victims of domestic violence. i Emergency awards in cases of extreme need. WHAT IS NOT COVERED? i Property damage or loss. i Pain and suffering. i Expenses not directly resulting from the crime.

3 OFFICE OF THE ATTORNEY GENERAL " STATE OF TEXAS FORM 06-17F JOHN CORNYN JUNE 2000 APPLICATION For Texas Crime Victims Compensation Si desea hablar con alguien en español, marque esta cajita por favor. Victim The victim is the person who was injured or killed as a result of the crime. PLEASE PRINT CLEARLY IN BLACK INK OR TYPE. 9 Español Victim s Last Name First Name Middle Name Street Address (APT Number) City State/Zip Code Mailing Address City State/Zip Code (Area Code)Home Phone Number (Area Code)Work Phone Number Sex: 9 Male Social Security Number Date of Birth 9 Female Type of assistance needed (Check all that apply): 9 Loss of Earnings 9 Loss of Support 9 Medical 9 Counseling 9 Funeral or Burial 9 Relocation 9 Crime Related Travel 9 Child or Dependent Care 9 Crime Scene Clean-up 9 Replacement of Property Seized as Evidence 9 Other Claimant The claimant is a person, other than the victim, who had expenses directly as a result of the crime, or an immediate family member of the victim who requires counseling as a result of the crime. Use additional pages if more than two claimants. Claimant s Last Name First Name Middle Name Street Address (APT Number) City State/Zip Code Mailing Address City State/Zip Code (Area Code)Home Phone Number (Area Code) Work Phone Number Sex: 9 Male Relationship to Victim 9 Female Social Security Number Date of Birth Type of assistance needed (Check all that apply): 9 Loss of Earnings 9 Loss of Support 9 Medical 9 Counseling 9 Funeral or Burial 9 Relocation 9 Crime Related Travel 9 Child or Dependent Care 9 Crime Scene Clean-up 9 Replacement of Property Seized as Evidence 9 Other Additional Claimant s Last Name First Name Middle Name Street Address (APT Number) City State/Zip Code Mailing Address City State/Zip Code (Area Code)Home Phone Number (Area Code) Work Phone Number Sex: 9 Male Relationship to Victim 9 Female Social Security Number Date of Birth Type of assistance needed (Check all that apply): 9 Loss of Earnings 9 Loss of Support 9 Medical 9 Counseling 9 Funeral or Burial 9 Relocation 9 Crime Related Travel 9 Child or Dependent Care 9 Crime Scene Clean-up 9 Replacement of Property Seized as Evidence 9 Other

4 APPLICATION FOR TEXAS CRIME VICTIMS COMPENSATION (CONTINUED) Crime Please complete with as many details as you have available. This information is important to reaching a decision on your application. Date of Crime Police Report Number or CPS Number Prosecutor Case Number Location of Crime (Street Address, City, County, State) Law Enforcement Agency Notified Did the victim know the suspect? 9 YES 9 NO If yes, in what way? Suspect s Name Describe the crime and injuries. Please use additional pages if necessary: Please check the box below that best describes the type of crime that occurred: 9 Adult Sexual Assault 9 Child Sexual Assault 9 Child Physical Abuse 9 Assault (Non-Family) 9 Aggravated Assault 9 Domestic Violence 9 DWI or Vehicular Crime 9 Elder Abuse 9 Homicide 9 Other (Please specify): Employment Was the victim employed on the date of the crime? 9 YES 9 NO Was the victim self-employed on the date of the crime? 9 YES 9 NO Job Title or Occupation Victim s Employer on Date of Crime Employer s Address City State Zip (Area Code) Phone Insurance and Reimbursement Sources By law, you must first use all existing sources of financial assistance or reimbursement before receiving payments from the Compensation Fund. Crime Victims Compensation must first verify application to these sources and the amount received, if any, before determining reimbursement. Do you have any of the following? Please check Yes or No on all boxes. Yes No Yes No Medicare? 9 9 Medicaid? 9 9 Health Insurance? 9 9 Burial Insurance? 9 9 T.A.N.F.? 9 9 Workers Compensation? 9 9 Auto Insurance? 9 9 Home Insurance? 9 9 Disability Insurance? 9 9 Social Security? 9 9 Veteran s Benefits? 9 9 Other? (Describe) Medicare Number Medicaid Number Health Insurance Company Name, address, phone number, group policy number If crime was motor vehicle related, please include auto insurance company and policy numbers for both victim and suspect, if available. Civil Lawsuit and Attorney Have you filed or will you file a civil lawsuit in relation to this crime? 9 Yes 9 No Attorney s Name (Area Code) Phone Number Address City State and Zip Code Please complete the questions on the back of this page. (2)

5 APPLICATION FOR TEXAS CRIME VICTIMS COMPENSATION (CONTINUED) IMPORTANT OPEN RECORDS NOTICE: Please read each statement and check one of the boxes. provided to Crime Victims Compensation is available to the public upon request. The Texas Open Records Act allows you the opportunity to inform Crime Victims Compensation that you do not want Crime Victims Compensation to release your name, address, social security number, and other identifying information. However, if you are awarded benefits, the law allows public access to the amount of the award and your name. Please check one of the following statements: I DO NOT WANT CRIME VICTIMS COMPENSATION TO ALLOW PUBLIC ACCESS TO MY NAME, ADDRESS, OR ANY OTHER IDENTIFYING INFORMATION ABOUT ME. I DO WANT CRIME VICTIMS COMPENSATION TO ALLOW PUBLIC ACCESS TO MY NAME, ADDRESS, OR ANY OTHER IDENTIFYING INFORMATION ABOUT ME. NOTE: If you do NOT select one of the above options, your personal information WILL be open to public access. Department of Justice In order to comply with regulations from the United States Department of Justice, we must collect the following information on the victim of the crime. This information is for statistical purposes only. It will not be used in determining whether the victim is eligible for Crime Victims Compensation benefits. Was the victim handicapped at the time of the crime? 9 Yes 9 No Ethnic Group: 9 American Indian or Alaskan Native 9 Black 9 Hispanic 9 White 9 Asian or Pacific Islander 9 National Origin (Country of Birth): Source of Referral (Where did you find out about this program?): 9 Public Service Announcement 9 Compensation Program 9 Advocacy Group 9 Victim Assistance Program 9 Poster, Brochure, etc. 9 Hospital 9 Law Enforcement 9 Other: (3)

6 OFFICE OF THE ATTORNEY GENERAL " STATE OF TEXAS J OHN C ORNYN Affidavit Important: This affidavit is part of your application and must be completed and signed before action can be taken on the application. SUBROGATION AGREEMENT: In accordance with Texas Code of Criminal Procedure, Article 56.52, I agree to notify the Crime Victims Compensation Program (CVC) of the Office of the Attorney General in writing before I file a lawsuit against another party as a result of this crime. I further agree that I shall not settle or resolve any such action without written authorization from CVC. If I recover any money by judgment, settlement, or other collateral source as a result of the incident that gave rise to this claim, I agree to repay CVC for any and all amounts that CVC has awarded to me. I agree that Travis County, Texas will have jurisdiction over any cause of action that arises between me and the Office of the Attorney General as a result of this claim. AUTHORIZATION FOR RELEASE OF INFORMATION: I hereby authorize any financial institution, social service agency, government agency, hospital, physician, mental health facility, counselor, psychologist, psychiatrist, employer, insurer, or other persons with information relating to financial, health, or employment status to release information concerning this application for benefits to the employees of the Crime Victims Compensation Program of the Office of the Attorney General of Texas as needed to process this claim. This information is to include, but is not limited to, financial, employment, diagnosis, and treatment information. A copy of this signed release will be considered the same as the original. AFFIRMATION AND AUTHORIZATION: I swear and affirm under penalty of perjury under the laws of the State of Texas (Penal Code 37.02) that the information provided in the Application for Texas Crime Victims Compensation and any additional information that I provide are true and correct to the best of my knowledge. I understand that the Attorney General of the State of Texas or any agent or representative of the office has the right to verify the information provided. I understand that if false, intentionally incomplete, or misleading information is provided, my application will be denied and I may be subject to civil and administrative penalties under Texas Code of Criminal Procedure, Chapter 56. NOTE: You must be eighteen years of age or older to sign this application, unless you are legally married. Victim s or Claimant s Signature Printed Name Date Date of Birth Social Security Number Relationship to Victim If someone assisted you with this application, list the name and phone number above. (4)