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ASSOCIATED APPLICATION ID:

Enter if known

Application For Crime Victim Compensation

Section 1 must be completed for all applications. If you are filing this

Example:

application on behalf of someone else, put their information in

FIRST NAME:

Section 1 and your information in Section 3. Please print clearly and

complete all sections that apply.

Check This Box if You Are a Parent/Guardian Applying on Behalf of a Minor Witness to Violent

LAST NAME:

Crime. Minor witnesses are eligible for mental health treatment only. Claimant is under age 18, a

witness in close proximity to a violent crime, but is neither the crime victim nor related to the victim.

Provide available victim, crime or other information in all sections.

Section 1 Claimant

SECTION 1 MUST BE COMPLETED FOR ALL APPLICATIONS

A separate application must be filed for each person seeking assistance.

The claimant is the person who has expenses or is seeking assistance as a result of a crime.

FIRST NAME:

MIDDLE NAME:

LAST NAME:

DATE OF BIRTH (MM/DD/YYYY):

GENDER: M F

SOCIAL SECURITY NUMBER:

Does the claimant have a Social Security number?

Yes

Relationship to victim:

Self

Other

If other, describe:

From the date of the crime to the present, has the claimant been in prison, on probation, or on parole because of a felony?

Yes

Mailing Address:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Apartment or Unit #):

CITY:

STATE:

ZIP:

HOME TELEPHONE:

WORK TELEPHONE:

Ext.

CELL PHONE:

E-MAIL:

If you are an adult victim and the expenses are for you,

skip to Section 4. If not, continue to Section 2

E N G

For more information call: 1.800.777.9229

Hearing impaired, please call

the California Relay Service (711)

www.calvcp.ca.gov

Mail completed application to:

California Victim Compensation Program PO Box 3036, Sacramento, CA 95812-3036

or deliver to your local

Victim Witness Assistance Center

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-V-07-005 (Rev. 12/12) [ENG]

Page 1 of 7

Section 2 Crime Victim

The crime victim is the person who was injured, threatened with injury, or killed due to the crime.

FIRST NAME:

MIDDLE NAME:

LAST NAME:
DATE OF BIRTH (MM/DD/YYYY):
GENDER:	M	F

SOCIAL SECURITY NUMBER:

Does the victim have a Social Security number?

Yes

From the date of the crime to the present, has the victim been in prison, on probation, or on parole because of a felony?

Yes

Mailing Address:

IF VICTIM IS DECEASED, DATE OF DEATH:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Apartment or Unit #):

CITY:

STATE:

ZIP:

HOME TELEPHONE:

WORK TELEPHONE:

Ext.

CELL PHONE:

E-MAIL:

If you are completing this application on behalf of a minor or an incapacitated adult, continue to Section 3 If not, skip to Section 4

Section 3 Parent or Guardian (Applicant)

This section is for parents or guardians of minors or incapacitated adults listed in Section 1.

Relationship to the person listed in Section 1:

Parent

Guardian

Social Worker

Other, describe:

FIRST NAME:

MIDDLE NAME:

LAST NAME:

DATE OF BIRTH (MM/DD/YYYY):

GENDER: M F

SOCIAL SECURITY NUMBER:

Do you have a Social Security number?

Yes

From the date of the crime to the present, have you been in prison, on probation, or on parole because of a felony?

Yes

Mailing Address:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Apartment or Unit #):

CITY:

STATE:

ZIP:

HOME TELEPHONE:

WORK TELEPHONE:

Ext.

CELL PHONE:

E-MAIL:

Continue to Section 4

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-V-07-005 (Rev. 12/12) [ENG]

Page 2 of 7

Section 4 Information About Your Expenses

For the victim of the crime, the following benefits may be available. Please check the crime-related expenses you are

requesting. Please attach copies, or a list, of any crime-related bills.

Medical and/or dental expenses

Mental health treatment

Income loss (if you missed work because of the crime)

Moving or relocation expenses

Home security improvements

Home or vehicle modifications (for a victim disabled because of the crime) Job retraining (for a victim disabled because of the crime)

Crime scene clean-up

Other:

For someone other than the victim of the crime, the benefits below may be available. Please check the crime-related

expenses you are requesting. Please attach copies, or a list, of any crime-related bills.

For minor witnesses to violent crime, only mental health benefits are available. Proceed to Section 5.

Mental health treatment

Wage loss (up to 30 days if a minor dies or is hospitalized)

Loss of support (for dependents of a deceased or disabled victim) Funeral and/or burial expenses

Crime scene clean-up

Home security improvements

Medical expenses for a deceased victim

Continue to remaining sections

EMERGENCY AWARD REQUEST:

Emergency awards may be requested in certain situations. An emergency award is intended to pay for crime-related expenses in cases where you will suffer serious financial hardship if crime-related expenses are not immediately paid. Substantial hardship means you would not have any money left for necessities like food or rent after you paid for crime-related bills. Qualifying emergency awards are generally paid within 30 calendar days of receipt of the application.

Do you need to request an emergency award?

Yes

Section 5 Crime Information

Law Enforcement Agency Name:

NAME OF THE LAW ENFORCEMENT AGENCY TO WHICH THE CRIME WAS REPORTED: (Includes Child Protective Services)

Date(s) crime occurred

FROM: (If on one day only, enter date here)

TO:

DATE CRIME WAS REPORTED:

TYPE OF CRIME:

DESCRIBE INJURIES:

LOCATION OF CRIME: (if known) Address, Intersection, Area, etc:

CRIME REPORT NUMBER:

COUNTY WHERE CRIME OCCURRED:

Person who committed the crime (suspect), if known:

FIRST NAME:

LAST NAME:

MIDDLE NAME:

Suspect Unknown

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-V-07-005 (Rev. 12/12) [ENG]

Page 3 of 7

Section 6 Representative Information (A representative is not needed to apply for victim compensation.)

This section is for representatives only, including victim advocates and attorneys. Victim Assistance Center Advocates need only provide phone, name, center #, sign and date. Attorneys, please fill out this section completely.

FIRST NAME:

MIDDLE NAME:

LAST NAME:

TELEPHONE:

Mailing Address:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Suite #):

CITY:

STATE:

ZIP:

ORGANIZATION NAME:

VICTIM WITNESS ASSISTANCE CENTER NAME:

Representative’s signature:

Date:

JP/VWC #:

For Attorneys Only:

State Bar Number:

Federal Tax ID:

Are you requesting payment pursuant to

Government Code Section 13957.7(g)?

Yes

Section 7 How Did You Find Out About the Program?

Law Enforcement

District Attorney

Medical Provider

Card or Booklet

Child Protective Services

Adult Protective Services

Media (TV, Radio, Newspaper, etc.)

Other:

Mental Health Provider

Victim Witness Assistance Center

Billboard or Poster

Section 8 Federal Reporting Information

The following voluntary information is for the person receiving compensation and is used for statistical purposes only to comply with federal regulations.

Ethnicity:

African American

Caucasian

Asian, Pacific Islander

Native American

Hispanic

Other:

Is the victim disabled?

Was the victim disabled prior to the crime?

Yes

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-V-07-005 (Rev. 12/12 [ENG]

Page 4 of 7

Section 9 Insurance Information

Please check all available sources that could be applied to your claim. The California Victim Compensation Program (CalVCP) is the payer of last resort. We may contact your insurance company as a potential reimbursement source. List insurance contact information below or on an additional sheet and attach.

Health Medi-Cal Medicare

INSURANCE COMPANY NAME:

Auto/

Vehicle

Workers’ Compensation

Homeowners/Renters None

TELEPHONE:

Other:

Mailing Address:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Suite #):

CITY:

STATE:

ZIP:

Name of Insured:

FIRST NAME:

MIDDLE NAME:

LAST NAME:

POLICY NUMBER:

GROUP NUMBER:

Have you filed an insurance claim related to this crime?

Yes

Undecided

Is the victim disabled? / ¿La víctima está incapacitada?	No	Yes / Sí	No
Section 10 Employer Information Yes / Sí

Please list the victim's employer. If you are a parent/guardian seeking wage loss benefits because a minor victim was hospitalized or is deceased, list your employer.

EMPLOYER'S BUSINESS NAME:

Contact Person:

FIRST NAME:

LAST NAME:

OK to contact employer?

Yes

TELEPHONE:

Mailing Address:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Apartment or Suite#):

CITY:

STATE:

ZIP:

Is or was the victim self-employed?

Did the victim miss work as a result of crime-related injuries?

Did the crime occur while the victim was on the job or at the workplace?

Yes

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-V-07-005 (Rev. 03/12 [ENG]

Page 5 of 7

Section 11 Civil Suit Information

Have you filed, or do you plan to file, a civil suit related to this crime?

Yes

Note: If you decide to file a civil suit, by law, you are required to notify CalVCP within 30 days of filing the action.

Attorney’s Name:

FIRST NAME:

MIDDLE NAME:

LAST NAME:

TELEPHONE:

Mailing Address:

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Suite #):

CITY:

STATE:

ZIP:

Your application for crime victim compensation is almost complete

►Print the application and then enter all available information.

►Attach copies of any documentation that supports your application for crime victim compensation, including copies of crime-related bills, insurance, or anything relating to the crime. Save original documents for your records.

►Please read the next page carefully, sign and date, and send to the address indicated or deliver to your local Victim Witness Assistance Center.

►CalVCP will send you a letter acknowledging that your application has been received. The acknowledgment letter will include additional information about the benefits requested on your application.

►A CalVCP representative may contact you for additional information if you were not able to provide it with your application.

►For any questions about victim compensation, you can contact your local Victim Witness Assistance Center or call CalVCP at 1-800-777-9229.

STATE OF CALIFORNIA VICTIM COMPENSATION AND GOVERNMENT CLAIMS BOARD

FORM VCGCB-V-07-005 (Rev. 12/12 [ENG]

Page 6 of 7

This page MUST be signed and dated

Section 12 Information Release

I give permission to any healthcare provider; any medical biller, any funeral director or similar persons, any employer, any police or other government agency, including the Department of Justice, the Social Security Administration, the State Franchise Tax Board, and the Federal Internal Revenue Service; any insurance company; or any other person or agency, to provide information relating to this application, including medical (including, but not limited to history or physical records, consultation reports, pathology reports, discharge summaries, operative reports, X ray and other radiology reports, laboratory reports, chart notes, narrative reports, and billing records), mental health, and felony conviction records, to the California Victim Compensation Program (CalVCP) or its representatives, for the purpose of determining eligibility for CalVCP benefits. This permission also applies to all sources of recovery for the claimed losses, including but not limited to, health or medical benefits, unemployment or disability benefits, Social Security benefits (Social Security disability, Supplemental Security income, and/or retirement, including the supporting medical and/or mental health records), and Veteran benefits. I also give permission for the release of federal and state tax information, including tax returns, for the purpose of verifying income. I hereby waive all legal privileges to any of this information required by CalVCP regarding my claim.

I agree that a photocopy or fax of this signed form is as valid as the original, and my signature gives permission for the release of all specified information.

I agree that CalVCP or its representatives may pursue restitution from the convicted offender in this matter to recover monies paid to me by CalVCP and that by filing this application I have authorized use of information in this application and subsequent claim files to pursue restitution from the convicted offender.

In order to verify or process this application, I agree that CalVCP or its representatives may provide information about this application, and the information contained in this application, to any representative named on this application, government agency, or health care provider or other provider of services, and may pay the provider directly if payment of these services is approved.

I agree that I may revoke this authorization at any time. The revocation must be in writing. The revocation will take effect when CalVCP receives it, but I may be deemed ineligible for CalVCP benefits once the revocation is received by CalVCP. However, no healthcare provider may condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I am entitled to a copy of this authorization except in limited circumstances. I agree that information disclosed under this authorization may be redisclosed by the recipient as required by law and this redisclosure may no longer be protected by federal or state law.

I agree that the authorizations and agreements herein will expire ten (10) years after the date of my signing this form.

Signed:

Date:

(Parent or guardian must sign if victim is a minor or incapacitated.)

Section 13 My Agreement to the California Victim Compensation Program

As required by California law, I will contact and repay the California Victim Compensation Program (CalVCP) if I, or anyone on my behalf, receives any payments from the offender, a civil lawsuit, an insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt of benefits from CalVCP, in the amount of the total benefits granted by the Program. I understand I may be responsible for repaying CalVCP any amount for which it is later determined that I was not eligible. I will notify CalVCP if I hire an attorney to represent me in any action related to this crime or if I pursue any action on my own.

Any monies I receive from CalVCP for moving/relocation expenses, improving home security, or for modifying a home or vehicle for a disabled victim will be used only for those purposes. If I am a victim of domestic violence receiving moving/relocation expenses, I will not tell the offender my home address nor allow the offender on the premises at any time, or I will seek a restraining order against the offender.

In the event that I am compensated for any pecuniary loss by the California Victim Compensation Program and the State of California subsequently receives compensation for the same loss on my behalf from the perpetrator (including any monies received through a restitution order) or from any other source, I hereby assign to the Victim Compensation and Government Claims Board any and all rights to such duplicate compensation.

I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my knowledge and belief. I understand that I may be found to be ineligible for benefits, and that action may be taken to recover benefits I receive if I provide information that is false, intentionally incomplete, or misleading.

Signed:

Date:

(Parent or guardian must sign if victim is a minor or incapacitated. County social workers, see section 13a.)

Printed Name:/ Nombre Escrito:

Section 13a For County Social Workers Only

As required by California law, I will contact and inform the California Victim Compensation Program (CalVCP) if I learn the claimant receives any payments from the offender, a civil lawsuit, an insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt of benefits from CalVCP.

I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my knowledge and belief. I understand that the claimant may be found to be ineligible for benefits, and that action may be taken to recover benefits the claimant receives if the claimant provides information that is false, intentionally incomplete, or misleading.

Signed:

Date:

Printed Name:/ Nombre Escrito:

Mail completed application to:

Victim Compensation & Government Claims Board

PO Box 3036, Sacramento, CA 95812-3036

- or -

deliver to your local Victim Witness Assistance Center

For more information call:

1-800-777-9229

Hearing impaired, please call

the California Relay Service (711)

Helping California Crime Victims Since 1965 www.calvcp.ca.gov

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-V-07-005 (Rev. 12/12 [ENG]

Page 7 of 7

Question	Answer
Form Name	Form Vcgcb V 07 005
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	California, 1965, VCGCB-V-07-005, Escrito

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