Form Vcgcb Vcp 005 PDF Details

When individuals fall victim to crimes, the aftermath often encompasses not only emotional and physical scars but also financial burdens. Recognizing this, the STATE OF CALIFORNIA CALIFORNIA VICTIM COMPENSATION PROGRAM offers a beacon of hope through Form VCGCB-VCP-005, an application for Crime Victim Compensation. This form is meticulously designed to cater to the varied needs of victims or their representatives, ensuring a systematic approach to applying for assistance. It mandates that each claimant, the person seeking assistance due to crime-related expenses, complete the application with detailed personal and crime-related information. From the outset, the form clarifies who qualifies as a claimant and outlines the necessary steps if you are applying on behalf of someone else, emphasizing assistance for both direct victims and witnesses of violent crimes. Sections span from personal information to crime details, expense claims, and even information regarding the victim’s insurance to ensure a comprehensive overview. Additionally, it accommodates minor witnesses and parental guardians applying on their behalf, with a clear distinction in available benefits based on the applicant's relation to the crime. This effort by the California Victim Compensation Program thereby not only provides financial relief but also stands as a testament to a structured support system for victims in the aftermath of crime.

QuestionAnswer
Form NameForm Vcgcb Vcp 005
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesvictimcompensat ionapp_eng form vcgcb vcp 005

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Application for Crime Victim Compensation

ASSOCIATED

APPLICATION ID:

Enter if known

Section 1 Claimant

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

Section 1 must be completed for all applications. The claimant is the person who has expenses or is seeking assistance as a result of a crime. If you are filing this application on behalf of someone else, put their information in Section 1 and your information in Section 3.

Preferred Spoken Language:

Preferred Written Language:

 

FIRST NAME:

 

 

 

 

 

MIDDLE NAME:

 

 

LAST NAME:

 

 

 

 

 

 

 

 

 

GENDER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to victim:

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY # (No dashes):

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the claimant have a Social Security number?

 

(MMDDYYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET NUMBER AND NAME OR P.O. BOX:

 

 

 

 

From the date of the crime to the present, has the claimant been in prison,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

on probation, or on parole because of a felony?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME TELEPHONE:

 

Address 2 (Apartment or Unit #):

 

 

 

 

 

CITY:

 

 

 

 

 

 

 

STATE:

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK TELEPHONE:

Ext.

 

CELL PHONE:

 

E-MAIL:

 

 

 

 

 

 

 

 

 

 

E-MAIL TYPE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

If you are an adult victim and the expenses are for you, skip to Section 4

If not, continue to Section 2

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:

 

 

 

GENDER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY # (No dashes):

 

 

 

DATE OF BIRTH

 

IF VICTIM IS DECEASED,

Does the victim have a Social Security number?

 

 

 

(MMDDYYYY):

 

DATE OF DEATH (MMDDYYYY):

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Apartment or Unit #):

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

CITY:

 

STATE:

 

ZIP:

 

HOME TELEPHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK TELEPHONE:

 

Ext.

 

CELL PHONE:

 

E-MAIL:

 

E-MAIL TYPE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-VCP-005 (Rev. 08/14) [ENG] Page 1 of 6

Section 3 Parent or Guardian (Applicant)

This section is for parents or guardians of minors or incapacitated adults in Section 1. Please indicate your relationship to the person listed in Section 1:

FIRST NAME:

SOCIAL SECURITY # (No dashes):

Does the applicant have a Social Security number?

MIDDLE NAME:

 

LAST NAME:

GENDER:

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

(MMDDYYYY):

 

From the date of the crime to the present,

 

 

 

 

have you been in prison, on probation, or on

 

 

 

 

 

 

 

 

parole because of a felony?

 

 

 

 

 

 

 

 

Mailing Address

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Apartment or Suite #):

 

 

 

CITY:

 

 

 

STATE:

 

ZIP:

 

 

HOME TELEPHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK TELEPHONE: Ext.

 

CELL PHONE:

 

E-MAIL:

 

 

 

 

 

 

E-MAIL TYPE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continue to Section 4

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

Moving or relocation expenses

Job retraining

(for a victim disabled because of the crime)

Other crime-related expense(s):

Mental health treatment

Home security improvements

Crime scene clean-up

Income loss

(if you missed work because of the crime)

Home or vehicle modifications

(for a victim disabled because of the crime)

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

Funeral and/or burial expenses

Medical expenses for a deceased victim

Wage loss

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

Crime scene clean-up

Loss of support

(for dependents of a deceased or disabled victim)

Home security improvements

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

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-VCP-005 (Rev. 08/14) [ENG] Page 2 of 6

Section 5 Crime Information

 

Law Enforcement Agency Name

 

Date(s) crime occurred

 

 

 

 

NAME OF THE LAW ENFORCEMENT AGENCY TO WHICH THE CRIME WAS REPORTED:

 

FROM:

If on one day,

TO:

 

 

 

 

 

 

 

 

 

 

 

 

enter here

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

\

 

 

 

 

 

 

DATE CRIME WAS REPORTED:

 

CRIME REPORT NUMBER: DESCRIBE INJURIES:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location of Crime (If known)

 

 

 

 

 

 

 

 

 

Address, Intersection, Area, etc:

 

 

 

Address 2 (Apt or Ste #): CITY:

 

 

 

 

STATE:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY WHERE CRIME OCCURRED:

Person who committed the crime (suspect), if known

TYPE OF CRIME:

 

FIRST NAME:

 

MIDDLE NAME:

LAST NAME:

 

 

 

 

 

 

 

 

 

 

 

 

SUSPECT UNKNOWN

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.

 

ORGANIZATION NAME:

TAX ID:

 

 

 

STATE BAR #:

 

TELEPHONE:

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME:

MIDDLE NAME:

 

 

 

LAST NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (Suite #):

 

CITY:

 

 

 

 

 

STATE:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Attorneys Only:

 

 

 

 

 

 

For Victim Assistance Center Staff Only:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you requesting payment pursuant to

 

 

 

 

 

 

 

JP/VWC #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Government Code Section 13957.7(g)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature and date required for all representatives

Attorney/Representative's signature:

Date:

Section 7 How Did You Find Out About the Program?

Law Enforcement

Adult Protective Services

Billboard or Poster

District Attorney Mental Health Provider

Card or Booklet

Medical Provider

Victim Witness Assistance Center

Other:

Children’s Protective Services Media (TV, Radio, Newspaper, etc.)

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-VCP-005 (Rev. 08/14) [ENG] Page 3 of 6

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

Asian, Pacific Islander

Hispanic

Caucasian

Native American

Other:

Is the victim disabled?

Was the victim disabled prior to the crime?

Section 9 Insurance Informationt

Please list your insurance information below. The California Victim Compensation Program (CalVCP) is the payer of last resort. We may contact your insurance company as a potential reimbursement source.

If you have no insurance of any kind, check here:

Health Insurance

HEALTH INSURANCE COMPANY NAME:

 

POLICY NUMBER:

 

GROUP NUMBER:

 

TELEPHONE:

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY:

Name of Insured

FIRST NAME:

 

MIDDLE NAME:

 

LAST NAME:

 

 

 

 

 

 

 

 

 

 

STATE: ZIP:

Have you filed an insurance claim related to this crime?

Auto/Vehicle Insurance (Includes car, truck, motorcycle, motorhome, boat, jet ski, airplane, etc.)

AUTO INSURANCE COMPANY NAME:

 

POLICY NUMBER:

 

TELEPHONE:

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

STREET NUMBER AND NAME OR P.O. BOX: Address 2 (Suite #): CITY:

Name of Insured

FIRST NAME:

 

MIDDLE NAME:

 

LAST NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE: ZIP:

Have you filed an insurance claim related to this crime?

Other Insurance

Please check any additional insurance sources that could be applied to your application:

Medi-Cal

Medicare

Workers’ Comp

Other:

If you have more than one insurance provider, please list on a separate piece of paper and mail with your application.

STATE OF CALIFORNIA

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-VCP-005 (Rev. 08/14) [ENG] Page 4 of 6

Is the victim disabled? / ¿La víctima está incapacit da?

Yes / Sí

No

Yes / Sí

No

Section 10 Employer Information

 

 

 

 

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.

 

 

 

Contact Person

 

 

 

 

 

 

 

 

 

OK to contact

 

EMPLOYER'S BUSINESS NAME: FIRST NAME:

 

 

LAST NAME:

 

 

TELEPHONE:

 

Ext.

 

 

employer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET NUMBER AND NAME OR P.O. BOX:

Address 2 (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?

If you have more than one employer, please list on a separate piece of paper and mail with your application.

Section 11 Civil Suit Information

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

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: Ext.

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

►After entering all available information, print the application.

►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

CALIFORNIA VICTIM COMPENSATION PROGRAM

FORM VCGCB-VCP-005 (Rev. 08/14) [ENG] Page 5 of 6

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1. Begin filling out your Form Vcgcb Vcp 005 with a selection of essential fields. Get all of the information you need and make certain nothing is omitted!

Writing segment 1 of Form Vcgcb Vcp 005

2. Once your current task is complete, take the next step – fill out all of these fields - WORK TELEPHONE, Ext, CELL PHONE, EMAIL, EMAIL TYPE, Check This Box if You Are a, If you are an adult victim and the, If not continue to Section, Section The crime victim is the, Crime Victim, FIRST NAME, MIDDLE NAME, LAST NAME, GENDER, and SOCIAL SECURITY No dashes Does with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Crime Victim, EMAIL, and Check This Box if You Are a of Form Vcgcb Vcp 005

3. In this specific step, look at Address Apartment or Unit, CITY, STATE, ZIP, HOME TELEPHONE, WORK TELEPHONE, Ext, CELL PHONE, EMAIL, EMAIL TYPE, If you are completing this, STATE OF CALIFORNIA, CALIFORNIA VICTIM COMPENSATION, FORM VCGCBVCP Rev ENG, and Page of. All these will have to be taken care of with utmost accuracy.

Filling in section 3 in Form Vcgcb Vcp 005

It is easy to make a mistake while filling out your If you are completing this, consequently make sure to go through it again prior to when you finalize the form.

4. The subsequent part requires your details in the subsequent parts: This section is for parents or, FIRST NAME, MIDDLE NAME, LAST NAME, GENDER, SOCIAL SECURITY No dashes Does, DATE OF BIRTH MMDDYYYY, Mailing Address STREET NUMBER AND, From the date of the crime to the, Address Apartment or Suite, CITY, STATE, ZIP, HOME TELEPHONE, and WORK TELEPHONE. Always fill out all requested info to go further.

Writing segment 4 of Form Vcgcb Vcp 005

5. Last of all, this last segment is precisely what you'll have to finish prior to using the PDF. The blanks under consideration include the following: Medical andor dental expenses, Moving or relocation expenses, Job retraining for a victim, Other crimerelated expenses, Mental health treatment, Home security improvements, Crime scene cleanup, Income loss if you missed work, Home or vehicle modifications for, For someone other than the victim, For minor witnesses to violent, Mental health treatment, Funeral andor burial expenses, Medical expenses for a deceased, and Wage loss up to days if a minor.

Funeral andor burial expenses, Job retraining for a victim, and Medical andor dental expenses of Form Vcgcb Vcp 005

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