Crime Victims Compensation Application

CRIME VICTIMS COMPENSATION APPLICATION State of Illinois Court of Claims State of Illinois Attorney General APPLICATION INSTRUCTIONS · Who should fill out the application? A person who was the victim of a violent crime should fill out the application. If the victim is under the age of 18 or under a legal disability, then the victim's parent or legal guardian should fill out the application. If the victim is deceased, a relative of the victim should fill out the application. The application must be signed by the victim or the victim's parent or legal guardian if the victim is under 18 or under a legal disability. · Documents. Please send copies of all the documents you have with the completed application (e.g., police report, plenary order of protection, civil no-contact order, hospital or doctor bills). If you do not have all the documents, send whatever documentation you have with the completed application. Collect copies of any additional information so that you will have it when we contact you. · Police reports. To complete our investigation, we must get a police report for the incident. If you have the police report number, please include it in the crime section. If you do not have the number, please provide as much information about the crime as possible. · Please provide all of the requested information. Attach additional sheets if the application does not provide sufficient space. Mail your completed application to: Office of the Illinois Attorney General Crime Victims Compensation Bureau 100 West Randolph Street, 13th Floor Chicago, IL 60601 · Address or phone number change. Once you have submitted an application, you must let us know if your address or phone number changes; without the correct information, your claim may not be recommended for payment. Send a letter informing us of your new contact information. · If we determine that you are eligible for the program, additional forms will be sent to you. These forms must be filled out and returned to our office within 30 days before any expenses can be reimbursed. · If you need help completing this application or would like referrals for services, contact the Office of the Illinois Attorney General at 1-800-228-3368 (Voice), 1-877-398-1130 (TTY). American LegalNet, Inc. www.FormsWorkFlow.com For assistance, call 1-800-228-3368 (Voice) 1-877-398-1130 (TTY) PAGE 1 of 8 Section I. Victim and Claimant Information · If you were the victim of a violent crime and you are over the age of 18, please fill in the victim information only. You will also be the claimant so it is not necessary for you to repeat your contact information in Part B. The claimant is someone who is applying for compensation due to a violent crime. · If you are applying on behalf of a victim (i.e., you are the parent of a minor child or the relative of a deceased victim) please put the victim's information in Part A and your contact information in Part B. The person who fills out Part B should also be the person signing the application. · Your correct information is necessary for our office to contact you with further questions and to send documents. If it is not correct, you may not be able to receive payment. · A Social Security number is requested but it is not necessary. · An advocate works with crime victims and provides assistance and referrals. You do not need an advocate to apply for compensation. However, if you are working with an advocate and you would like us to try and obtain information about your case from your advocate, please list the information in Section C. · If there is another individual who you would like us to discuss your claim with, please provide that person's name in Section C. If the analysts working on your claim are unable to reach you, your claim may not be recommended for payment. It is helpful, but not necessary, to have another means of getting information about the claim to avoid becoming ineligible for the program. · If you are the spouse or parent of a victim applying for your own expenses, please complete a separate application for yourself. Section II. Crime and Court Information · This section collects information about the crime and any court proceedings that have taken place as a result of the crime. Not all of the sections may apply to your situation; provide as much information as you have available. · Include a police report number, if known. · Please submit one application per crime. Section III. Losses Claimed · This section collects information on what types of compensable loss you may have incurred as a result of the crime. Compensable losses are those types of losses that are covered by the Crime Victims Compensation Program. · If you have any questions or would like to have more information on the types of expenses that are compensable, please call 1-800-228-3368 (Voice), 1-877-398-1130 (TTY). Section IV. Medical Information and Benefits · Complete this section if you are applying for medical, dental or counseling expenses. If you are not interested in applying for these expenses, check "no" and leave this section blank. · If you are a spouse or parent applying for counseling expenses you incurred because of the crime against your spouse or child, fill out a separate application listing yourself as the victim. · Counseling expenses can only be considered for payment if the counseling is provided by one of the following: licensed clinical psychologist, licensed clinical social worker, licensed clinical professional counselor, licensed professional counselor or a Christian Science practitioner. Section V. Employment Information · Complete this section if you are applying for lost earnings. Reimbursement is available for earnings lost due to time off recovering from the crime and attending court. · If you are a spouse or parent applying for lost earnings for time you missed from work to care for your spouse or child, fill out a separate application listing yourself as the victim. For assistance, call 1-800-228-3368 (Voice) 1-877-398-1130 (TTY) American LegalNet, Inc. www.FormsWorkFlow.com PAGE 2 of 8 Section VI. Funeral/Burial Information & Death Benefits · Fill out this section if you are applying on behalf of a deceased victim. · Loss of support is provided when a crime victim was working prior to the crime, but due to his or her death is no longer able to provide monetary support or meet a legal obligation to provide monetary support. · We require information on all of the dependents of the victim befor