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Application For Crime Victim Compensation - Ohio
| Application For Crime Victim Compensation Form. This is a Ohio form and can be used in Victim Services Attorney General Office Statewide . |
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ElIGIbIlITY CHECKlIST If you answer "yes" to all these questions, you may be eligible for help from this program. Theapplicationisbeingfiledwithintwoyearsofthedate of the crime. Minors have until their 20thbirthdaytofilefor compensation. Thecrimewasreportedwithin72hours(unlessthereisa goodreasonfordelay)andthevictimcooperatedwiththe reasonable requests of law enforcement. Thevictimwasnotcommittingacriminalactthatcausedor contributedtotheinjuries. The victim has no collateral source of payment for the compensation they are seeking. WHO CAN GET HELP? The Ohio Victims of Crime Compensation Program helps victimswithcertainout-of-pocketexpensescausedwhenpeople arephysicallyinjured,emotionallyharmed,orkilledbyviolent criminalacts.Programcostsarepaidentirelybycriminalfines andnotbyOhio'staxpayers. WHO IS NOT ElIGIblE? Theoffender. Anyonewhoengagedinafelonyofviolenceordrugtraffickingwithin10yearspriortothecrimethatcausedtheinjuryor duringthependencyoftheclaim. Avictimorclaimantwhohasbeenconvictedofafelony within10yearspriortothecrimethatcausedtheinjuryor duringthependencyoftheclaim. Aclaimantwhohasbeenconvictedofachildendangering ordomesticviolenceoffensewithin10yearspriortothe crimethatcausedtheinjuryorduringthependencyofthe claim. Anyoneinjuredwhileincarceratedandservingasentence. WHAT ArE SOmE COSTS THAT mAY bE PAID? Medicalandrelatedexpenses. Counselingforfamilymembersofvictimsforspecific crimes(upto$2,500each).Maximum$7,500perclaim. Wages lost from not being able to work. Replacement services. Crimesceneclean-up/repairforsafety(upto$750). Evidencereplacement(upto$750). Funeralexpenses(upto$7,500.) ArE THErE lImITS ON COmPENSATION? Yes.Compensationcannotbepaidforstolen,damaged,or lostproperty,orforpainandsuffering. Compensationisnotpaidforcostspayablebyother sources. Thetotalawardmustbe$50ormorebeforepayment ismade. OHIO VICTIMS Of CRIME COMPENSATION PROGRAM APPlICATION fOR COMPENSATION TAPE ONLY -- DO NOT STAPLE innocent victims of a violent crime, financial assistance may be available. If you or your family members are For more information, call: Ohio Victims of Crime Compensation Program Attorney General's Office 150 E. Gay St., 25th Fl. Columbus, OH 43215 (614) 466-5610 TOll-FrEE NumbErS: For Specific Case Information (800) 582-2877 For General Information (877) 584-2846 (877-5VICTIm) Also visit us at www.ag.state.oh.us American LegalNet, Inc. www.FormsWorkflow.com OHIO VICTIMS Of CRIME COMPENSATION PROGRAM APPlICATION fOR CRIME VICTIM COMPENSATION (Please Type or Print Using Blue or Black Ink) After your application has been filed, the law may provide for payment of an emergency award to qualified claimants who, because of the crime, no longer have access to resources that provide basic necessities. Call (877) 584-2846 to request an emergency award. THIS DOCUMENT IS A PUBLIC RECORD. EXCEPT FOR INFORMATION THAT IS PROTECTED BY STATE OR FEDERAL LAW, INFORMATION YOU PROVIDE ON THIS APPLICATION IS SUBJECT TO PUBLIC DISCLOSURE UPON REQUEST. SECTION 1: VICTIM INFORMATION Personinjuredorkilledasaresultofthecrime.Ifthereismorethanone victim, there must be a separate application for each victim. Victim'sName(First/MiddleInitial/Last)__________________________________________________________________________ StreetAddress _______________________________________________________ EmailAddress ___________________________ City ________________________________________ County _______________________ State ___________Zip _____________ Social Security # __________________________ Date of Birth ____________________________ Victim is/was: a. male female b. single married separated divorced widowed Hasthevictimbeenarrestedfor,orconvictedof,anyfelony,domesticviolence,orchildendangeringwithin10yearspriortotheinjury, orsincetheinjury? Yes No HasthevictimlivedinanystateotherthanOhiointhepast10years? Yes No If yes, list each state ______________________ HomePhone() _____________ WorkPhone() ________________ Cell() ___________________________ SECTION 2: CLAIMANT INFORMATION (If different than victim). Claimant cannot be a minor. Claimant'sName(First/MiddleInitial/Last) _______________________________________________________________________ StreetAddress _______________________________________________________ EmailAddress ___________________________ City ________________________________________ County _______________________ State ___________Zip _____________ Social Security # _________________________ Date of Birth ____________________________ Relationship to victim _____________________________________________________________ Claimant is: a. male female b. single married separated divorced widowed Hastheclaimantbeenarrestedfor,orconvictedof,anyfelony,domesticviolence,orchildendangeringwithin10yearspriortotheinjury, orsincetheinjury? Yes No HastheclaimantlivedinanystateotherthanOhiointhepast10years? Yes No If yes, list each state ___________________ HomePhone() __________________________________________WorkPhone() ___________________________ SECTION 3: CRIME INFORMATION Date of Crime _____________________ DateCrimeReported ____________________________ _____________ Didithappenwhileonthejob?YesNo Location/AddressofCrime _________________________________________________________ (City/State/County) _________________________________________________________________________________________ Ifnotreportedwithin72hours,pleaseexplain: Lawenforcementagencycrimereportedto ________________________________________________________________________ SuspectedOffender(s) (Useadditionalsheet)Name ____________________________________________________________________________________ StreetAddress/City/State/Zip Descriptionofthecrime:HomicideAssaultRobberySexualAssaultDomesticViolenceOther _____________________________________________________________________________________________ Whatwerethevictim'sinjuries? ___________________________________________________________________ Didthevictimdieasaresultofthecrimeinjuries?YesNo _______________ Date of Death: _____________ American LegalNet, Inc. www.FormsWorkflow.com SECTION 4: COMPENSATION REQUESTED (Check all that apply) Medicalandrelatedexpenses ProtectionOrderFees Counseling for victim Counselingforimmediatefamily member(s)ofavictim Lost wages Funeralandburial Crime scene clean-up Clothing/itemsheldasevidence,bylawenforcement Futurelossofsupport/carefordependentsofadeceased victim Replacementservices(Payingsomeonetodowhatthevictim woulddosuchashousecleaning,childcare,errands,
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