West Virginia Crime Victims Compensation Fund Application

CRIME VICTIMS COMPENSATION FUND 1900 KANAWHA BLVD E RM W-334 CHARLESTON WV 25305-0610 OFFICE OF THE COURT OF CLAIMS CRIME VICTIMS COMPENSATION FUND APPLICATION FOR WEST VIRGINIA CRIME VICTIMS COMPENSATION Revised February 2011 g Include all the documentation you can - if you have a copy of the police report, hospital or doctor bills, please send with the application. g If you do not have this documentation, do not wait to mail the application if you are near the two-year deadline. Send the application as soon as you have it completed and follow-up with the documentation later. g Keep this page so that you will have our address and telephone number. g Be sure to let us know of any address or telephone number changes. g If you need help completing the application, contact us or check with your local prosecuting attorney's Victim Assistance Coordinator, if available. g Sign this Application (Page 3) in front of a notary public. Failure to notarize will delay the processing of your claim. Mail your completed application to: CRIME VICTIMS COMPENSATION FUND 1900 KANAWHA BLVD E RM W-334 CHARLESTON WV 25305-0610 304.347.4850 877.562.6878 (toll free) Fax 304.347.4915 e-mail: cvictims@wvlegislature.gov www.legis.state.wv.us/joint/victims/main.cfm American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION THE WEST VIRGINIA CRIME VICTIMS COMPENSATION FUND g Provides financial assistance to victims of crime for related expenses that g cannot be reimbursed from insurance or other sources. Compensation for medical, funeral/burial expenses, earning losses, mileage to a medical treatment facility and to court for the prosecution of the offender, mental health counseling, crime scene cleanup, and relocation expenses. Administered by the West Virginia Court of Claims. g HOW THE SYSTEM IS FUNDED g Every person who is convicted of or pleads guilty to a misdemeanor or felony offense, other than a non-moving traffic violation, is assessed additional court costs, which are transmitted to the State Treasurer for deposit into the Crime Victims Compensation Fund. No tax dollars are used. g WHO CAN FILE A CLAIM? g Any innocent victim who suffers personal injury as the result of a crime. g Any individual who is the dependent of a deceased victim of crime. (A dependent is one who has received over one half of his/her support from the victim.) WHAT IS REQUIRED? g The crime must be reported to law enforcement officials within 72 hours. g The claimant must fully cooperate with law enforcement officials. g The claim for compensation must be filed within 2 years of the date of the crime. IS THERE A LIMIT TO THE AMOUNT RECOVERABLE? g In injury claims, the maximum is $35,000.00. g In death claims, the maximum is $50,000.00 (including $7,000.00 for funeral and burial expenses). g The Claim Investigator reviews the claim and files a Finding of Fact and HOW IS A CLAIM PROCESSED? g g Recommendation. A Judge of the Court of Claims evaluates the claim without a hearing and renders a decision. A hearing on the matter will be held if either the claimant or the Claim Investigator disagrees with the decision rendered. IS THE LOSS OF OR DAMAGE TO PROPERTY RECOVERABLE? IS THERE A FILING FEE? g No. Lost, damaged, or stolen property or MONEY is not subject to an award. However, prosthetic devices, eyeglasses, dentures, etc., are compensable. g No. g No. If a claimant seeks the services of an attorney, reasonable fees will be paid by the Fund at no cost to the claimant. DO YOU NEED AN ATTORNEY? If you are not sure of your eligibility, call us for additional information. We care! American LegalNet, Inc. www.FormsWorkFlow.com WEST VIRGINIA CRIME VICTIMS COMPENSATION FUND Office Use Only Date Received: __________________ Claim No.: CV- __________________ Judge: ________________________ 1900 Kanawha Blvd., E., Room W-334 Charleston, WV 25305-0610 Voice: 304.347.4850 & 877.562.6878 Fax: 304.347.4915 Email: cvictims@wvlegislature.gov APPLICATION IMPORTANT: COUNTY WHERE CRIME OCCURRED: PLEASE COMPLETE ALL SECTIONS and PRINT CLEARLY 1 Page DATE OF CRIME _______/_________/_________ CLAIMANT Information Section 1 ______________________________________________________________________________________________ CLAIMANT'S FIRST NAME MI CLAIMANT'S LAST NAME ______________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________________________________________________ CITY STATE/ZIP CODE ______________________________________________________________________________________________ E-MAIL ADDRESS (please print clearly) RELATIONSHIP TO VICTIM: SELF OTHER (SPECIFY):______________________________ Section 2 DATE OF BIRTH: SOCIAL SECURITY NUMBER: MALE OR FEMALE: MARITAL STATUS: SINGLE HOME PHONE: WORK PHONE: MARRIED SEPARATED DIVORCED ( ( ) ) - Section 3 EMPLOYMENT (earning losses) Revised February 2011 DID CLAIMANT HAVE AN EARNINGS LOSS DUE TO THIS CRIME? NO IF YES, LIST AMOUNT OF EARNINGS LOSS $___________________________ IF YES, LIST DAYS UNABLE TO WORK DUE TO INURY: ____________________________________________________________________________________________________________________________ EMPLOYER'S FULL NAME:___________________________________________________________________ EMPLOYER'S TELEPHONE NUMBER: _____________________________________________ EMPLOYER'S FULL MAILING ADDRESS: __________________________________________________________________________________________________________________________________________ Zip Street or PO Box Number City State WORK-RELATED REMARKS:_____________________________________________________________________________________________________________________________________________________ VICTIM Information IF CLAIMANT IS THE VICTIM, SKIP SECTIONS 4 AND 5 Section 4 ______________________________________________________________________________________________ VICTIM'S FIRST NAME MI VICTIM'S LAST NAME ______________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________________________________________________ CITY STATE/ZIP CODE ______________________________________________________________________________________________ E-MAIL ADDRESS (please print clearly) Section 5 DATE OF BIRTH: SOCIAL SECURITY NUMBER: MALE OR FEMALE: MARITAL STATUS: SINGLE HOME PHONE: WORK PHONE: MARRIED SEPARATED DIVORCED ( ( ) ) - NARRRATIVE - In our o