Connecticut > Statewide > Victim Services
Survivor Benefits Application JD-VS-8SB - Connecticut
| Survivor Benefits Application Form. This is a Connecticut form and can be used in Victim Services Statewide . |
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SURVIVOR BENEFITS APPLICATION JD-VS-8SB 10/12 We understand that this is a very difficult time for you and your family. We are here to help. If you have any questions about filling out this application or the Compensation Program, please call us toll-free at 1-888-286-7347. Please know that it is important that you tell us if your contact information changes. If we cannot reach you, your claim may be closed or you may miss important deadlines set by state law. SECTION 1 - VICTIM INFORMATION Name of victim (last, first, middle) Address Gender: m Female m Male m Other Birth date City Age State Zip SECTION 2 - CLAIMANT INFORMATION The claimant is the person who has expenses because of the crime. Parents and legal guardians of a minor child (under 18 years old) and legal guardians of an incapacitated adult must also fill out Section 3. If you are applying for loss of support for minor child(ren) of the victim, please fill out Section 3 and Section 7. Name of claimant (last, first, middle) Address Home telephone Primary language spoken Work telephone Birth date City Cell phone Gender: m Female Email m Male Age State Zip m Other Relationship to victim: m child m brother m spouse m sister m parent m grandchild m grandparent m stepchild m spouse's parent m stepparent m half-brother m other m half-sister m adopted child m party to a civil union m administrator of the estate An adult claimant, the parent/legal guardian of a minor child (under 18 years old), or the legal guardian of an incapacitated adult must sign Section 12 of this application. Applications that are not signed will be returned. American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 - PARENT/LEGAL GUARDIAN INFORMATION This section is for parents and legal guardians of children under 18 years old and legal guardians of an incapacitated adult. If you have your own expenses because of the crime, please fill out another application and list yourself as the claimant. (Legal guardians or conservators must provide a copy of the court order.) Name of parent or legal guardian (last, first, middle) Address Home telephone Primary language spoken Work telephone City Cell phone Gender: m Female How are you related to the claimant? State Email m Male m Other Zip SECTION 4 - ATTORNEY REPRESENTATION Please check if an attorney is representing you on this application, a civil lawsuit, or both and provide the attorney's contact information. m Representing me on this application m Representing me in a civil lawsuit Name of attorney (last, first, middle) Address Work telephone Fax number Name of firm City Juris number State Zip SECTION 5 - STATISTICAL INFORMATION How did you find out about the Victim Compensation Program? m community advocate m family member m friend/acquaintance m hospital m Infoline 211 m medical provider m mental health provider m Office of Adult Probation m OVS victim advocate m OVS web page m police m poster/brochure m private attorney m prosecutor/state's attorney m public service announcement m telephone book m other Statistics are voluntary and needed for federal reporting requirements. m white m hispanic m asian m other m black/african american m native hawaiian/pacific islander m american indian/alaskan native m unknown American LegalNet, Inc. www.FormsWorkFlow.com SECTION 6 - CRIME INFORMATION Please fill out this section. Type of crime: m homicide m dui m hit and run m other Briefly describe the crime: Date of crime Date crime was reported to police Police department incident number Address and city or town where crime happened Police department crime was reported to Name of police officer investigating the crime Was the crime reported to the police within 5 days? m yes m no (If no, please explain) Was someone arrested for the crime? m yes m no m unknown Name of person(s) arrested, if known Did the person(s) arrested go to court? m yes m no m unknown If yes, court location Docket number, if known SECTION 7 - LOSS OF FINANCIAL SUPPORT Are you applying for Loss of Support Compensation? m yes m no Please list all of the financial dependents (spouse and children) of the victim. For a child, attach a copy of the child's birth certificate. For a spouse, attach a copy of the marriage certificate. (Attach additional pages, if needed). Dependent's name Address (street, city, state, zip) Relationship to victim Birth date (mm/dd/yyyy) Guardian (if minor) American LegalNet, Inc. www.FormsWorkFlow.com SECTION 8 - COUNSELING/MEDICAL EXPENSES Please fill out this section if you are applying for medical/mental health benefits. List all of the hospitals, doctors, counselors, ambulance services, and others who provided treatment or services because of the crime and list the prescriptions (drugs) you were given because of it (attach additional pages, if needed) and include copies of any crime related bills. Provider Telephone Address City State Zip SECTION 9 - COURT RELATED BENEFITS Please fill out this section if you have expenses for attending court proceedings. State law defines relatives of the victim that are eligible for this benefit. Please check your relationship to the victim below. If your relationship is not listed below, you are not eligible for this benefit. m child (natural, step, and adopted) m spouse's parent m stepparent m spouse m parent m grandchild m grandparent m brother (natural and half) m sister (natural and half) Are you applying for mileage or travel expenses to attend court proceedings? m yes m no Are you applying for lost wages to attend court proceedings? m yes m no (If yes, please fill out below.) Employer Name Address Contact name City Telephone number State Zip SECTION 10 - FUNERAL EXPENSES Please fill out this section if you are applying for reimbursement of funeral expenses. If an estate has been opened, the administrator of the estate must file an application for benefits. Anyone who paid all or a portion of the funeral expenses would have to apply to the estate for reimbursement. Please attach a copy of the funeral bill and death certificate. The estate administrator must also attach a copy of the court appointment. Name of funeral home Address Contact name City Telephone number State Zip American LegalNet, Inc. www.FormsWorkFlow.com SECTION 11 - INSURANCE & OTHER FINANCIAL RESOURCES This section must be filled out. Please check yes or no for each type of victim compensation benefit listed below that you are applying for. If you are applying for that benefit, you must check yes or no for ea
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