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Crime Victims Compensation Application - Illinois
| Crime Victims Compensation Application Form. This is a Illinois form and can be used in Court Of Claims Secretary Of State . |
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CRIME VICTIMS COMPENSATION APPLICATION STATE OF ILLINOIS STATE OF ILLINOIS COURT OF CLAIMS ATTORNEY GENERAL PLEASE READ ATTACHED INSTRUCTION SHEET AND USE BLACK INK OR TYPE. For HELP call the Attorney Generals Office at 312-814-2581 or 1-800-228-3368. SECTION I. CLAIMANT & VICTIM INFORMATION (See Instructions for Section I.) CLAIMANT (IF NOT VICTIM) Claimants Name:___________________________________ Date of Birth: __________ ___ Male ___ Female Street Address:________________________________________________________________________ _____ City: _____________________________________________ State:________ Zip Code:__________________ Home Telephone:_____________________ Work/Other Daytime Telephone(s):_____________________ Social Security No.: _____________________ Relationship to Victim:_____________________ VICTIM Victims Name:_____________________________________ Date of Birth: __________ ___ Male ___ Female Street Address:________________________________________________________________________ ______ City: _____________________________________________ State:________ Zip Code:__________________ Home Telephone:____________________ Work/Other Daytime Telephone(s):____________________ Social Security No.: ___________________ Marital Status:___ Single ___ Married ___ Divorced ___ Widowed Does the victim suffer from an actual or perceived disability that substantially limits activity? ____ Yes ___ No THE FOLLOWING INFORMATION IS USED FOR STATISTICAL PURPOSES ONLY IN COMPLIANCE WITH FEDERAL REGULATIONS. PROVIDING THIS INFORMATION IS VOLUNTARY AND WILL NOT AFFECT YOUR APPLICATION. Ethnic Group:___ Black (not Hispanic) ___ White (not Hispanic) ___ Hispanic (any Spanish culture) ___ American Indian or Alaskan Native ___ Asian or Pacific Islander (including Indian subcontinent) How did you learn about Crime Victims Compensation? _______________________________________________ SECTION II. CRIME INFORMATION (See Instructions for Section II.) Date of Crime: _________________ Date Crime Reported:___________ Police Report No.: ________________ Street Address where crime occurred:_____________________________________________________________ City: _______________________________________________________________ County: ________________ Name of Agency/Department crime reported to:_____________________________________________________ City: _______________________________________________________________ County: ________________ PAGE 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Describe crime: ________________________________________________________________________ ______ ________________________________________________________________________ ___________________ Name of offender, if known: __________________________ Was offender arrested? ___ Yes ___ No ___ Unk Has offender been charged in court? ___ Yes ___ No ___ Unk If so, what is the charge? _________________ Criminal Case No.: ___________________ Circuit Court of:______________ County Court Date:__________ SECTION III. MEDICAL INFORMATION & BENEFITS (See Instructions for Section III.) Are medical expenses claimed? ___ Yes ___ No Are counseling expenses claimed? ___ Yes ___ No Describe the injuries: ________________________________________________________________________ ___ List the names and addresses of all doctors, hospitals, counselors or other medical service providers who treated the victim for injuries arising from the crime as described above. Medical Provider Address Date(s) of Service Amount of BillAre further medical expenses anticipated? ___ Yes ___ No Please indicate what sources of payment are available to cover the above listed charges: Source Unk No Yes Benefit Providers NamePrivate, Group, Employer, or Union Health Insurance Public Aid or AFDC Medicare or Medical Assistance Workers Compensation Veterans Administration, Champus SSI or SSDI Proceeds of Personal Injury or other Litigation If the victim has received or may receive direct payment from any of the following sources, please list: Source Yes No Monthly Amount Paid From (date) Paid To (date)Public Aid or AFDC SSI or SSDI Other (specify) Table continued on Page 3. PAGE 2 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3Workers Compensation Unemployment Compensation Private, Group, or Employers Health Plan Union or other Disability Plan Other (specify) List any other sources of payment :________________________________________________________________ SECTION IV. FUNERAL & BURIAL INFORMATION & DEATH BENEFITS (See Instructions for Section IV.)A. Funeral and Burial Are funeral and/or burial expenses claimed? ___ Yes ___ No If so, in what amount? $ ____________ Have these expenses been paid? ___ Yes __ No Name of person who paid:_________________________ Relationship, if any, between victim and person who paid:______________________ B. Insurance If any dependent(s) of the victim have received or may receive accident or life insurance, please list below: Name of Insurance Company Name of Beneficiary Amount Paid or DueC. Loss of Support At the time of death, did the deceased victim contribute financial support for any dependants? ___ Yes ___ No If so, in what amount per month? $__________ Please list minor (18 years or under) dependents and any other dependents of victim: Name of Dependent Relationship to Victim Date of Birth Name of Legal GuardianSECTION V. EMPLOYMENT INFORMATION (See Instructions for Section V.) Are lost wages claimed? ___ Yes ___ No If so, was the victim employed during the six (6) months immediately prior to the crime? ___ Yes ___ No Please list all employment during the six (6) months prior to the crime: _ Name of Employer Address Phone No. Victims Job Title Victims Net Mo. Wages PAGE 3 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4Did the victim miss time from work due to the crime? ___ Yes ___ No If so, did the victim receive disability benefits or sick pay? ___ Yes ___ No Has the victim returned to work? ___ Yes ___ No If so, date:____________________ SECTION VI TUITION (See Instructions for Section VI.) Is tuition reimbursement claimed? ___ Yes ___ No If so, list name of school/college/university:_________________________________________________________ Address:__________________________________________________________ Phone:___________________ Semester(s) missed:_____________________________ Amount of tuition paid and unused: $ ______________ SECTION VII SUBROGAT
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