Form Dch 0560 PDF Details

Form DCH 0560 is a state form that can be used by taxpayers to claim their exemption from California's sales and use tax. This form can be used to claim an exemption for yourself, your spouse, or your dependents. There are several eligibility requirements that must be met in order to qualify for this exemption, so it's important to understand what they are before you submit the form. If you have any questions about the process or need help filling out the form, you can contact the California Department of Tax and Fee Administration for assistance.

QuestionAnswer
Form NameForm Dch 0560
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesCompAppDCH 0560_359330_7 michigan department of community health crime victim compensation application form

Form Preview Example

CRIME VICTIM COMPENSATION APPLICATION

Michigan Department of Community Health

For Office Use Only

Claim Number

Other

Claim Examiner

AUTHORITY: PA 223 of 1976

COMPLETION: Is Voluntary, but is required if Crime Victim Compensation is desired.

The Department of Community Health is an equal opportunity employer, services, and programs provider.

INSTRUCTIONS:

Please PRINT CLEARLY or TYPE all information in this application.

You DO NOT need an attorney to file a claim.

If an attorney represents you in this claim, the attorney MUST file a Letter of Appearance with this application.

Information provided on this form is exempt from disclosure under the Freedom of Information Act.

You must sign your name and enter the date signed on Page 4 of this application.

Mail this application form to:

CRIME VICTIM SERVICES COMMISSION MICHIGAN DEPARTMENT OF COMMUNITY HEALTH 320 S. Walnut Street

LANSING MI 48913

Phone: (517) 373-7373 Fax: (517) 334-9462

Victim only toll free (877) 251-7373

Falsely presenting facts and circumstances to this commission, with the intent to defraud or cheat, WARNING: may be a crime if compensation is awarded.

SECTION 1 - Victim Information: (Complete this section for the person who was injured)

1.

Name of VICTIM (Last, First, Middle)

 

 

 

3.

Date of Birth

4. Social Security Number

 

 

 

 

 

 

 

 

2.

Address (Number and Street, Apartment Number, etc.)

 

5.

Home Telephone Number

Cell Phone Number

 

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

City

 

 

State

ZIP Code

 

6.

Work Telephone Number

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Marital Status:

 

 

 

 

 

 

 

8. Gender:

 

 

Single

Married

Separated

Divorced

 

Widowed

Male

Female

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 – Claimant Information:

(Complete this section ONLY if you are the Parent or Guardian of a Minor Victim OR the Survivor of a Deceased Victim)

1.

Name of CLAIMANT (Last, First, Middle)

 

 

3.

Date of Birth

 

 

4. Social Security Number

 

 

 

 

 

 

 

 

 

 

2.

Address (Number, Street, Apartment Number, etc.)

 

5.

Home Telephone Number

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

ZIP Code

 

6.

Work Telephone Number

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Marital Status

 

 

 

 

 

 

 

 

 

8. Gender

 

 

Single

Married

Separated

Divorced

 

Widowed

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

9.

Your Relationship to the Victim:

 

 

 

 

 

 

 

 

 

 

Spouse

 

 

Parent

 

 

Child

 

 

Sibling

 

 

Grandparent

 

 

Grandchild

 

 

Guardian

 

 

Other

 

 

 

 

 

 

 

10. Are you or were you dependent on the deceased victim for either:

 

 

 

 

10A. If YES, Monthly Amount

 

Primary Financial Support

...............................................

 

 

 

NO

YES

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10B. If YES, Monthly Amount

 

Child Support or Alimony

................................................

 

 

 

NO

YES

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DCH-0560 (Rev. 07-11) Previous Edition May BeUsed

Page 1 of 4

SECTION 3 – Crime Information:

(Complete this section and provide a copy of the Police Report if available)

1. Type of Crime (Check ONLY ONE)

 

 

 

Arson

Assault

Child Abuse

DWI / DUI

Homicide

Kidnapping

Motor Vehicle Accident

Robbery

Sexual Assault

Terrorism

 

 

Other (explain):

 

 

 

2. Was the person who caused the injury the victim’s spouse, former spouse, an individual with whom

YES

NO

 

 

the victim had a child in common, or a resident or former resident of the victim’s household?

 

 

 

 

 

 

 

 

 

 

 

 

3.

Date of Crime

4. Date Crime was Reported

5. County in which Crime Occurred

 

 

 

 

 

 

6.

Police or Sheriff Agency to which crime was reported

 

7. Incident Number

 

 

 

 

 

 

 

8.

Location of Crime (Number and Street)

City

State

 

ZIP Code

 

 

 

 

 

 

 

9.

Describe the Physical Injuries that result from this crime:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Brief Description of Crime:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

If the crime was NOT reported to Police/Sheriff within 48 hours, please explain the reason for the delay:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

If you are NOT filing this claim within 1 year of the crime, please explain the reason for the delay:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 4 – Restitution and Recovery Information:

(Complete this section, providing all information you currently have available)

1.

Name of Offender(s) if known

 

 

 

 

 

 

 

 

 

 

2.

Has the Offender(s) been charged in court?

 

 

 

 

 

YES (If YES, complete the questions 3, 4, & 5)

NO

UNKNOWN

 

 

 

 

 

 

3.

Name of Court

 

4. Court Case Number

 

 

 

 

 

 

 

 

5.

Court’s Mailing Address

 

City

State

ZIP Code

 

 

 

 

 

 

6.

Did the court order the offender to pay restitution to you?

 

 

 

 

 

YES (If YES, complete the questions 7, 8, & 9)

NO

UNKNOWN

 

 

 

 

 

7.

Restitution Order Date

8. Court Case Number

 

9. Amount Ordered

 

 

 

 

 

$

 

 

 

 

 

 

 

10.

Have you filed, or do you intend to file a civil court action?

 

 

 

 

 

YES (If YES, complete the questions 11, 12, 13, & 14)

NO

 

 

 

 

 

 

 

11.

Have you settled with a third party regarding this case?

 

 

 

 

 

YES (If YES, please attach a copy of the legal settlement)

NO

UNKNOWN

 

 

 

 

 

 

12.

Name of Attorney

 

13. Attorney’s Telephone Number

 

 

 

 

 

 

 

14.

Attorney’s Address (Number and Street, Suite, etc.)

City

State

ZIP Code

 

 

 

 

 

 

 

DCH-0560 (Rev. 07-11) Previous Edition May BeUsed

Page 2 of 4

SECTION 5 – Statistical Information for Crime Victim Program:

1. Please tell us how you first found out about the Crime Victim’s Compensation Program:

Prosecuting Attorney

Medical Provider

Attorney

Media, Brochure, or Poster

Police / Sheriff

Victim Service Agency

Friend / Acquaintance

Other

Federal Civil Rights Information: (Providing any of the following information is voluntary)

2. Race / Ethnic Background:

White

Asian / Pacific Islander

Black American Indian

Hispanic Multi-racial

3. If Disabled, check one

BEFORE Crime

As a RESULT of this crime

SECTION 6 - Claim Determination Information:

1. Check the Type of Compensation Benefits you are Requesting

 

Medical Expense Benefits for the Victim

 

Funeral Benefits for the Survivor(s)

 

Loss of Earnings Benefits for the Victim

 

Loss of Support Benefits for the Survivor(s)

2.

Have you or will you suffer a minimum out-of-pocket loss of $200?

3.

Have you lost at least 2 continuous weeks of earnings?

 

NO

YES

 

NO

YES

4.

Is your injury the result of a Criminal Sexual Assault?

5.

Are you Retired by reason of Age or Disability?

 

NO

YES

 

NO

YES (see question 6)

6.

Provide DATE and REASON for Retirement if Retired because of Age or Disability

 

SECTION 7 - Out-of-Pocket Expense Information: Please Submit itemized medical bills

(Complete this section ONLY if you are applying for Medical, Dental, Counseling, or Funeral Expenses)

IMPORTANT: Please enclose all available itemized bills for losses you are claiming. Include hospital, doctor, dentist, ambulance, radiology, therapy, prescription drugs, counseling, funeral home, cemetery, etc.

1.

PROVIDER NAME

2.CITY and STATE

3. TELEPHONE NUMBER

4. Will Additional Medical Treatment be Required? (Please explain):

SECTION 8 – Insurance and Other Collateral Source Information:

1. Please indicate which of the following source (if any) are available to pay any medical bills or out-of-pocket expenses: (check ALL that apply)

* Please attach any “Explanation of Benefits” statements that you have received to date.

Health Insurance *

Dental/Vision Insurance *

Veterans Administration *

Medicare *

Workers Compensation *

State Medical Plan

Automobile Insurance *

Homeowners Insurance *

Other Public Assistance

Medicaid

NONE OF THESE

OTHER (explain in #2)

2.

Please explain any “other” source from above

 

 

 

 

 

 

 

3.

Name of Primary Medical Insurer (if applicable)

4. Policy Number

5. Telephone Number

 

 

 

(

)

6.

Name of Secondary Medical Insurer (if applicable)

7. Policy Number

8. Telephone Number

 

 

 

(

)

9. Please indicate which of the following source (if any) are available to pay any funeral or burial expenses: (check ALL that apply)

* Please attach any “Explanation of Benefits” statements that you have received to date.

Life Insurance *

Burial Benefit Policy *

Family Independence Agency

Workers Compensation *

Automobile Insurance *

Veterans Benefits / Insurance

Social Security Death Benefit *

 

NONE OF THE THESE

10. Please explain any “other” source from above

OTHER (explain in #10)

DCH-0560 (Rev. 07-11) Previous Edition May BeUsed

Page 3 of 4

SECTION 9 – Income Information: Indicate YOUR HOUSEHOLD INCOME AND RESOURCES.

If Parent or Guardian of a Minor Victim, or the Survivor of a Deceased Victim, complete this section showing the CLAIMANT’S income.

1. Annual Household Income

$

IMPORTANT: Completion of Section 9 is required for ALL Applicants.

2.SOURCES OF EARNINGS OR SUPPORT: (check all that apply and indicate if received BEFORE or AFTER the injury)

* Attach a Benefits Determination

 

RECEIVED

* Attach a Benefits Determination

RECEIVED

 

BEFORE

AFTER

BEFORE

AFTER

only if you completed Section 10.

 

only if you completed Section 10.

 

 

 

 

 

 

Employment

 

FIP Grant, Food Stamps

*

*

Interest / Dividends

 

State Disability Insurance

*

*

Income Property, Land Contracts

 

Veterans Benefits, Military Allotment

 

 

 

Employer Disability, Sickness, or Accident Benefits

*

*

Alimony / Child Support

 

 

Workers’ Compensation

*

*

Life Insurance

 

 

Unemployment Compensation

*

*

None of these

 

 

Social Security Disability / SSI Benefits

*

*

Other (Explain):

 

 

Pension / Retirement Benefits

*

*

 

 

 

 

 

 

 

 

3.DEPENDENTS: Please List Names and Birth Dates of Victim’s Legal Dependents

If applying for loss of support; also attach a copy of the child’s birth certificate, and for a spouse, attach a copy of the marriage certificate.

SECTION 10 – Earnings Information:

(Complete Section 10 ONLY if you are applying for Loss of Earnings or Loss of Support)

INSTRUCTIONS:

Attach pay stubs showing the victim’s earnings at the time of the crime.

If at least 2 continuous weeks of work were missed, attach a doctor’s letter verifying this absence and the reason why.

If the victim is / was self employed, attach copies of income tax returns for the year before the crime, and the year of the crime, if available.

1.

Victim’s Employer Name

 

 

3.

Supervisor’s Name

 

 

 

 

 

 

 

 

2.

Employer’s Street Address

 

 

4.

Supervisor’s Telephone Number

 

 

 

 

 

(

)

 

 

 

 

 

 

City

State

ZIP Code

5.

Dates absent from work due to crime related injuries

 

 

 

 

From:

To:

6.

Name of Doctor who will verify Medical Disability

7. Doctor’s Telephone Number

 

 

 

 

 

(

)

 

8.

Is the Victim’s Wage Loss covered by Disability Insurance or Worker’s Compensation Insurance?

 

 

NO

 

 

 

YES

 

 

 

 

 

 

 

 

SECTION 11 – Authorization to Release Information, Repayment Requirement, Financial Hardship, and Declaration:

(Your Signature Below indicates your Understanding and Agreement to the following)

AUTHORIZATION FOR RELEASE OF INFORMATION:

I authorize any hospital, doctor, counselor, or other treatment provider who attended __________________________________________

(Name of Victim); any funeral director or other person who rendered services; any employer; any police or other local government agency, including State and Federal revenue services; any insurance company; or other organization having knowledge; to furnish to the Michigan Crime Victim Services Commission, or its representative, all information concerning the incident which led to the victim’s personal injury or death, and the claim made for compensation, including treatment, employment, insurance, or third-party payer information.

REPAYMENT REQUIREMENT:

I understand that payment by the victim compensation program is payment of last resort. If I receive a payment from another source for the same expenses, the State of Michigan is entitled to reimbursement up to the amount of any compensation awarded to me through the Crime Victim Services Commission. I also understand that my providers may be paid directly for debts that I owe.

FINANCIAL HARDSHIP:

I understand that my eligibility for crime victim’s compensation required that losses represent a serious financial hardship for me. I attest that there are no other financial resources or income available to me. I attest that un-reimbursed losses claimed in this application will cause me serious financial hardship.

DECLARATION:

I declare, under penalty of perjury, information on this form is true, correct, and complete to the best of my knowledge and belief.

Claimant’s Signature

Date of Signature

NOTE: A photocopy of this authorization is as effective

 

 

 

 

and valid as the original.

DCH-0560 (Rev. 07-11) Previous Edition May BeUsed

Page 4 of 4