Housekeeping

NORTHCAROLINADEPARTMENTOF

PUBLIC SAFETY

Section 1:

VICTIM

INFORMATION

Victim information is

requested for federal

reporting purposes.

VICTIM COMPENSATION APPLICATION

Section 2:

CLAIMANT

INFORMATION

Complete this section

if victim is deceased,

incompetent, or a minor.

Section 3:

INSURANCE

INFORMATION

We are payers of

last resort. All bills

must first be filed with

insurance companies.

Section 4:

CRIME

INFORMATION

Please complete

section with all requested

information and warrant-

based cases must submit

a copy of the warrant.

Victim Name Victim Date of Birth Mailing Address City State Zip Marital Status Social Security # (last six digits only) Home Phone Work Phone Email Gender Male Female Race Victim is: Claimant Name Claimant Date of Birth Mailing Address City State Zip Relationship to Victim Social Security # (last six digits only) Home Phone Work Phone Was the victim covered by medicare, medicaid, medical or health insurance? Yes No Insurance Company Policy # Address City State Zip Medicaid Number Medicare Number Brief description of what happened and the injuries sustained: Type of Crime Date of Crime Time Date Reported Time Name of Law Enforcement Agency Case # Location of Crime City County Name of Offender Relationship to Victim Has case gone to court? Yes No

Was restitution ordered? Yes No Amount $ Warrant # Name of Investigating Officer INJURIES

INFORMATION

Continued next page

Did victim receive injuries from the crime? No Yes (describe) Did victim receive medical treatment? No Yes (physician) Address City State Zip Please mail to:

North Carolina Department of Public Safety Victim Compensation Services 4232 Mail Service Center, Raleigh, NC 27699-4232 Phone: 919-***-**** Fax: 919-***-**** 1-800-***-**** (NC) www.ncdps.gov/dps-services/victim-services 2

Continued

Attach all itemized

medical bills related

to the injuries received

from the crime. If victim

is deceased, attach

funeral bill and a copy

of the death certificate.

Section 6:

ADDITIONAL

INFORMATION

Supply all additional

information as related.

Section 7:

CERTIFICATION

Please read carefully,

date and sign. Must be

18 or older to sign.

This authorization is

granted for a period of

two years from this date.

Section 5:

TYPES OF

ECONOMIC LOSS

Hospital where victim was treated Did victim receive counseling? No Yes (counselor) Address City State Zip Is victim deceased due to injuries from crime? No Yes Name of funeral home Phone Federal ID # Address City State Zip By signing below, you attest that the above information is true and accurate. Further, by signing below you understand and acknowledge that North Carolina General Statute section 15B-7(b) states that a person who knowingly and willfully presents or attempts to present a false or fraudulent, or a State officer or employee who knowingly and willfully participates or assists in the preparation or presentation of a false or fraudulent application is guilty of a Class 1 misdemeanor if the application is for a claim of not more than four hundred dollars ($400.00). If the application is for a claim or more than four hundred dollars ($400.00), the person is guilty of a Class I felony. Below choose all that apply: victim (v) claimant (c) Funeral/Burial (v) Lost wages (v) Medical/Dental (v) Mental Counseling (v) Other (v or c) Was victim employed at time of crime? Yes No (if no, do not compete employment information) Employer Phone Address City State Zip Has an attorney been retained for purposes of representing victim or claimant in a civil suit relate to crime? Yes No (Attorney name) Address City State Zip Was a civil suit filed or do you anticipate filing a civil suit as a result of the crime? Yes No Have you applied for other financial assistance? Yes No (Agency name) Address City State Zip Victim or offender auto insurance Address City State Zip I authorize Victim Compensation Services to request and obtain any information or records required to determine the eligibility of my claim for a period not to exceed the full processing of this application. I agree that if I recover any money from the offender or from any other source as payment for my injury, I will pay it to Victim Compensation Services or that amount may be deducted from the amount of compensation for which I am eligible.

I agree that the failure to immediately inform Victim Compensation Services of the existence of any other funds constituting payment for my injury may be considered fraud and that Victim Compensation Services may reduce or deny my claim or may initiate an action to recover funds previously paid. I agree that Victim Compensation Services may pay compensation directly to the provider for any unpaid expenses relating to this claim.

I understand that willfully and knowingly providing false information could result in this claim being disallowed and/or imprisonment of up to five years.

I certify under penalty of law that the information contained in this application is true to the best of my knowledge.

Signature Printed name Date

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