Crime Victim Compensation Application {DCH-0560}

CRIME VICTIM COMPENSATION APPLICATION Michigan Department of Health and Human Services Claim Number Cross Reference Number For Office Use Only AUTHORITY: PA 223 of 1976 COMPLETION: Is Voluntary, but is required if Crime Victim Compensation is desired. Information on this form is exempt from disclosure under the Freedom of Information Act. The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. INSTRUCTIONS Please PRINT CLEARLY or TYPE all information in this application. Separate application must be completed for each victim. · · · · · · Enclose copies of crime-related itemized medical, dental, burial or counseling bills received to date if not fully paid by insurance Submit Explanation of Benefit for each date of service that was not paid in full by your insurance Submit 2 or 3 paystubs paid just before the date of injury, showing gross, net and tax deductions if applying for loss of wages Submit a written disability statement from your physician verifying dates you were unable to work For assistance in completing this application, call the victim only toll free number 877-251-7373 or 517-373-7373 Return the completed application to the below address: Crime Victim Services Commission Grand Tower, Suite 1113 235 S. Grand Avenue PO Box 30037 Lansing, MI 48909 Fax: 517-373-2439 SECTION 1 - Victim Information: Complete this section for the person who was injured. 1. Name of VICTIM (Last, First, Middle) 2. Address (Number, Street, Apartment Number, etc.) City 8. Marital Status State ZIP Code 3. Date of Birth 5. Home Telephone Number 7. Work Telephone Number 9. Gender 4. Social Security Number 6. Cell Phone Number Single Married Separated Divorced Widowed Male Female SECTION 2 ­ Claimant Information: Please complete this section if the victim is a 1. Name of CLAIMANT (Last, First, Middle) 2. Address (Number, Street, Apartment Number, etc.) City 8. Marital Status State ZIP Code Minor Deceased 3. Date of Birth Incapacitated 4. Social Security Number 6. Cell Phone Number 5. Home Telephone Number 7. Work Telephone Number 9. Gender Single Spouse Grandparent Married Separated Parent Grandchild Divorced Child Guardian Widowed Male Sibling Other Female 10. Your Relationship to the Victim 11. Are you or were you dependent on the deceased victim for either Primary Financial Support NO YES If yes, monthly amount Child Support or Alimony NO YES If yes, monthly amount 12. Dependents: Please list names and Birthdates of ALL Victim's Legal Dependents Names Birthdates Names Birthdates DCH-0560 (Rev. 5-16) Previous edition may be used. 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 ­ Crime Information: Complete this section and provide a copy of the Police Report if available. 1. Type of Crime (Check ONLY ONE) Homicide Robbery Child Abuse/Neglect Human Trafficking Other (explain) Assault Arson Child Sexual Assault Terrorism DWI/DUI Burglary Child Pornography Fraud Financial Crimes Vehicular Crime (other) Sexual Assault Stalking Kidnapping 2. Was the person who caused the injury the victim's spouse, former spouse, an individual with whom the victim had a child in common, or a resident or former resident of the victim's household? YES 3. Date of Crime NO 4. Date Crime was Reported 5. County which Crime Occurred 7. Incident Number City State Zip Code 6. Police or Sheriff Agency to which crime was reported 8. Location of Crime (Number and Street) 9. Describe the Physical Injuries that resulted from this crime 10. Brief Description of Crime 11. If the crime was NOT reported to Police/Sheriff within 48 hours, please explain the reason for the delay 12. If you are NOT filing this claim within 1 year of the crime, please explain the reason for the delay SECTION 4 ­ Restitution and Recovery Information: Complete this section, providing all information you currently have available. 1. Name of Offender(s) if known 2. Has the Offender(s) been charged in court? YES (If YES, complete questions 3 & 4) 3. Name of Court 5. Did the court order the offender to pay restitution to you? NO 4. Court Case Number UNKNOWN YES (If YES, complete questions 6, 7 & 8) 6. Restitution Order Date 7. Court Case Number NO 8. Amount Ordered UNKNOWN $ 9. Have you filed, or do you intend to file a civil court action? YES (If YES, complete questions 10, 11, 12 & 13) 10. Have you settled with a third party regarding this case? NO NO 12. Attorney's Telephone Number City State Zip Code YES 11. Name of Attorney 13. Attorney's Address (Number, Street, Suite, etc.) UNKNOWN SECTION 5 ­ Statistical Information for Crime Victim Program: For statistical purposes only. Completion of this section is strictly voluntary. 1. Please tell us how you first found out about the Crime Victim's Compensation Program: Prosecuting Attorney Police/Sheriff 2. Race/Ethnic Background: White Non-Latino/Caucasian Asian Alaska Native Medical Provider Attorney Victim Service Agency Friend/Acquaintance Native Hawaiian or Other Pacific Islander Black-African American Hispanic or Latino American Indian Multi-Racial Other 2 of 4 Media, Brochure, or Poster Other 3. If Disabled, check one BEFORE Crime As a RESULT of this crime American LegalNet, Inc. www.FormsWorkFlow.com DCH-0560 (Rev. 5-16) Previous edition may be used. SECTION 6 ­ Claim Determination Information: 1. Check the Type of Compensation Benefits you are requesting. Medical Expense Benefits for the Victim Loss of Earnings Benefits for the Victim Counseling Grief Counseling for homicide only 2. Have you or will you suffer a minimum out-of-pocket loss of $200? Funeral Benefits for the Survivor(s) Loss of Support Benefits for the Survivor(s) Crime Scene Clean-up for homicide only 3. Have you lost at least 2 continuous weeks of earnings? YES YES NO NO YES YES NO NO 4. Is your injury the result of a Criminal Sexual Assault? 5. Are you Retired by reason of Age of Disability? SECTION 7 ­ If you are applying for MEDICAL, DENTAL, COUNSELING: Please complete this section, otherwise skip to Section 8. Please include all itemized medical bills, explanation of benefit and receipts. 1. Please indicate which of the following sources (if any) are available to pay any medical bills or out-of-pocket expenses: (check ALL that apply). Please attach any "Explanation