Ovs Application Form – Fill Out and Use This PDF

The OVS Application Form, issued by the New York State Office of Victim Services, offers a crucial pathway for innocent victims of crime, their relatives, dependents, legal guardians, and qualified Good Samaritans to claim compensation for financial burdens incurred that are not covered by insurance or other means. It outlines the types of expenses eligible for reimbursement, such as medical bills, loss of essential personal property, funeral expenses, and more, providing a thorough guide on how to apply and what documents are necessary for submission. Anyone impacted by crime is encouraged to review the application details and take the first step towards compensation by clicking the button below.

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Ovs Application Form PDF Details

Understanding the New York State Office of Victim Services (OVS) Claim Application is the first step toward obtaining compensation for victims and their families who have suffered due to crime. The OVS application is designed to provide financial relief for innocent victims of crime, certain relatives, dependents, legal guardians, and eligible Good Samaritans who face out-of-pocket expenses not covered by insurance or other means. The form outlines eligibility for coverage of various expenses including medical bills, loss of essential personal property, funeral costs, lost wages or support, and more. It also covers the application process, detailing the necessary documents such as police reports, medical bills, and proof of insurance claims, aiming to ensure applicants are well-informed. Importantly, the form reassures applicants that legal representation is not necessary to file a claim, but if chosen, legal fees up to $1,000 might be reimbursed if the claim is awarded. Besides monetary compensation, the application provides guidance on restitution from perpetrators, emphasizing the importance of keeping accurate records of all crime-related expenses. Furthermore, it addresses concerns such as what to do if you move or how to get help if you have questions about filling out the form. It's a comprehensive document that not only aids in the immediate financial aftermath of a crime but also in the longer journey of recovery and justice.

Question	Answer
Form Name	Ovs Application Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	claim ovs form printable, nys claim application, claim application instructions, claim application download

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New York State

Office of Victim Services

Claim Application and Instructions

How to Apply for Compensation

Who can apply for compensation?

Innocent victims of crime, certain relatives, dependents, legal guardians and eligible Good Samaritans can apply to the Office of Victim Services (OVS) for compensation of out-of-pocket expenses not covered by insurance or other resources.

What kinds of expenses can I get compensated for?

OVS offers compensation related to personal injury, death and loss of essential personal property.

The specific expenses OVS may cover include: Medical, pharmacy and counseling expenses

Loss of Essential Personal Property (up to $500, including $100 for cash)

Burial or Funeral Expenses (up to $6,000)

Lost Wages or Lost Support (up to $30,000) (Parents or guardians of hospitalized minor children may be eligible for this benefit.)

Transportation (court/medical)

Occupational/Vocational Rehabilitation

Security and Shelter

Crime scene clean-up (up to $2,500)

How do I ask for compensation?

Send us your completed OVS application along with copies of:

Police reports

Medical bills

Correspondence with insurance companies

or benefits plan saying if they will cover your loss Insurance cards

Receipts for essential personal property Death certificate and funeral contract

Victim’s birth certificate

What if I don’t have some of the papers OVS needs?

Send your application in right away. You can send the other documents later.

Do I need a lawyer to file a claim to OVS?

No. But, if you hire a lawyer to help you with this claim and it is awarded, you can ask OVS to reimburse up to $1,000 of the legal fees.

What if my property was lost, damaged or destroyed because of the crime?

If you are under 18, 60 or over, disabled or were injured, you may apply for benefits to replace your essential personal property or cash that was not covered by any other resource.

Essential means necessary for your health and welfare, like eyeglasses and clothes.

What if I move?

Send OVS a signed letter right away. Tell us your new address and phone number. Also let us know if your email address changes.

What if I have questions or need help filing a claim?

We can help you find a victim assistance program near you. Call us at: 1-800-247-8035

Or visit our website: www.ovs.ny.gov

It’s best to fill out the form completely, or it may take longer to process your claim.

Who can sign the claim?

Generally, the victim must sign the claim. However, if the victim is under 18, or is physically or mentally incapable of signing, then the legal guardian (the person receiving the benefits) must fill out section 2 of the claim and sign the claim.

If the victim died, the person asking for benefits must fill out section 2 of the claim and sign the claim.

Do I have to fill out the attached

HIPAA form?

Yes. Fill out one HIPAA form for each service provider. You can photocopy a blank form to make extra copies.

80 S. Swan Street	55 Hanson Place		65 Court Street
Albany, NY 12210-8002	Brooklyn, NY 11217-1523		Buffalo, NY 14202-3406
(518) 457-8727	(718) 923-4325		(716) 847-7992
www.ovs.ny.gov		1-800-247-8035

Rev. December 2013

Court Ordered Restitution Information

What is restitution?

Restitution is compensation paid to a victim by the perpetrator of a criminal offense for the losses or injuries incurred as a result of the criminal offense. It must be ordered by the Court at the time of sentencing, and is considered part of the sentence.

Restitution is NOT for payment of damages for future losses, mental anguish or “pain and suffering.”

When the District Attorney’s (DA) office advises the Court that you have requested restitution or when the victim impact statement contained in the probation investigation report (pre-sentence, pre-plea or pre-disposition report) indicates that the victim seeks restitution, the Court must order restitution unless the interests of justice dictate otherwise. When the judge does not order restitution, the judge must clearly state his/her reasons on the record.

What can I request as restitution?

You can ask for any expense you incur as a result of the criminal offense – even for items the OVS may not be able to reimburse. Restitution may include, but is not limited to, reimbursement for medical bills, counseling expenses, loss of earnings, funeral expenses, insurance deductibles and the replacement of stolen or damaged property.

Who is entitled to restitution?

Anyone who has been the victim of a criminal offense and has suffered injuries, economic losses or damages can seek restitution. Many times, victims who deserve restitution do not request it. This can occur because victims are not aware that they are entitled to restitution, or do not know what steps to take to go about receiving the restitution they deserve.

How do I ask for restitution?

You should contact the DA’s office and advise them of the extent of your injury, your out-of-pocket losses and the amount of damages you are requesting.

It is your responsibility to give the police, DA and, upon request, the local probation department copies of the bills and other documents showing the extent of your injuries, your out-of-pocket losses and the amount of damages you want considered by the Court. Your claim for restitution will be included in any probation investigation report (pre-sentence, pre-plea or pre-disposition report). Be sure to:

Keep accurate records such as original receipts of any expenses you have as a direct result of the criminal offense. Give copies of these receipts to the police, DA and local probation department.

You need to clearly explain your need for restitution as soon as possible to the DA, the victim/witness advocate, and the probation department. Plea agreements can occur within days of the actual criminal offense. If this information is not provided before the plea agreement and sentencing, you may have to pursue the perpetrator in Civil Court.

The DA is under an obligation to petition the Court to order restitution on your behalf.

In all felony criminal cases, many misdemeanor criminal cases and all juvenile delinquency and persons in need of supervision (PINS) cases, a pre-sentence or predisposition investigation report is required. The local probation department will contact you about the issue of restitution as it pertains to your case.

How is restitution determined?

The amount of restitution is based on proof of your out-of-pocket losses incurred as a result of the criminal offense. The

perpetrator has a right to object to the amount of restitution. The Court may hold a hearing on the issue of restitution where the Court may consider the perpetrator’s ability to pay. The DA’s office may contact you and ask you to testify at

the restitution hearing. If you have a concern about appearing personally in Court, you should explore alternatives with the DA assigned to your case.

If the OVS has paid your bills, the Court may order that restitution payments be made to the OVS for those paid items. It is important that you advise the DA’s Office that you filed a claim with the OVS.

If you filed a claim with the OVS, it is important that you advise the OVS if the Court orders the perpetrator to pay restitution.

Rev. December 2013

Read

How to Apply for Compensation before filling out this form.

Application for Compensation

New York State Office of Victim Services

Please print. Answer all questions. It is a crime to file a false claim!

Victim Assistance Program Use Only

OVS VAP ID#

Program Name/Phone

Advocate Name/Email

1Tell us about the victim.

Last Name

First Name

Social Security #

Date of Birth

Check here if you do not have one.

__ __ __ - __ __ - __ __ __ __

Mailing Address:

Street

Apt. # (or P.O. Box)

City

County

State (or Foreign Country)

Zip Code

Race/Ethnicity:

White

Black

Asian/Pacific Islander

Hispanic

American Indian/Alaskan Native

Other

Unknown

Marital Status:

Single

Married

Divorced

Separated

Widowed

Lives with partner

Gender:

Male

Female

Was the victim disabled at the time of the crime?

Yes

Unknown

How did you first hear about the Office of Victim Services?

Police

Hospital

District Attorney

Victim Assistance Program

Radio/TV

Brochure/Poster

Internet

Other

2If you are not the victim, and you are signing this claim, you are the claimant. Tell us about you. (See “Who can sign

the claim?” on the instructions page.)

Last Name				First Name		MI		Social Security #	Date of Birth
							Check here if you do not have one.
							__ __ __ - __ __ - __ __ __ __

Mailing Address:
Street	Apt. # (or P.O. Box)			City		County		State (or Foreign Country)	Zip Code
What is your relationship to the victim? (Check only one.)
Parent	Spouse	Child	Legal Guardian		Attorney	Other (Explain):

3Tell us about the crime.

The victim died because of:

Motor Vehicle (DWI)

Motor Vehicle (Other)

Terrorism

Arson

Human Trafficking

Other Homicide:

(Check only one.)

The victim was injured because of:

Assault		Stalking
Sexual Assault		Kidnapping
Child Physical Abuse		Terrorism
Child Sexual Abuse		Arson
Motor Vehicle (DWI)		Robbery
Motor Vehicle (not DWI)		Human Trafficking
Other (Explain):

The victim lost essential personal property

because of:

Burglary/Robbery/Larceny		Arson
Motor Vehicle (DWI)		Criminal Mischief
Motor Vehicle (not DWI)
Human Trafficking
Other (Explain):

Where did the crime happen? (Check only one.)	Work	Owned residence	Apt. Bldg.	Public Street
Subway/Bus Parking Lot Restaurant/Bar	School/School grounds Shopping Mall			Other (Explain):

Was this a domestic violence crime?	Yes
Was the victim driving a livery cab when the crime happened?	Yes
Was the victim’s property lost or damaged while trying to prevent or stop a
crime against someone else or while helping the authorities stop the crime? ....	Yes

No No

Unknown Unknown

Crime Report #: ________________ Police or criminal justice agency reported to: ______________________________

County where crime happened:Date of crime:______________ Date crime was reported: ______________

If more than 7 days between the date of crime and date the crime was reported, explain why: ____________________________________

_______________________________________________________________________________________________________________________________________________________________

If more than 1 year between the date of crime and the date you are filing this claim, explain why: ________________________________

_______________________________________________________________________________________________________________________________________________________________

Describe the crime in your own words: ____________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________

Rev. December 2013

Page 1 of 4

4 Tell us about the suspect. Suspect’s name (if you know):

Has the suspect been arrested for this crime? ..................

Has the suspect been prosecuted for this crime?..............

Does the suspect live in the same house as the victim

OR is the suspect a member of the victim’s family? ..........

Has the court issued an order of protection in this case?.. Has the DA asked the court to order restitution?

Did the court order the suspect to pay restitution? ............

Yes	No
Yes	No	Not Yet
Yes	No
Yes	No (If Yes, attach a copy.)
Yes	No	Not Yet

Yes (Amount $ _________ ) No

Not Yet

NOTE - If you are eligible for compensation, the OVS may be able to reimburse for the expenses listed below. These items should also be requested as part of court ordered restitution. Applicants are encouraged to share this information with prosecutors if there is a criminal case. See the Court Ordered Restitution Information page for important information about restitution.

5Tell us about your expenses related to this crime. (Check all that apply.)

Medical/Ambulance

Crime Scene Cleanup

Security Device/System

Counseling

Other (Explain):

Loss of Support

(Death Claim Only)

Vocational/Rehabilitation

Funeral/Burial

Lost Wages	Personal Transportation
DV Shelter	Medical
Moving/Storage	Court

Essential Personal Property

6List any essential personal property, like cash, eyeglasses, or clothing that needs to be replaced

because of this crime. (If none, skip to 7.)

Describe what was lost/damaged:

Cost

Describe what was lost/damaged:

Cost

1._________________________________________________ $ ______________________ 4. _________________________________________________ $ __________________________

2._________________________________________________ $ ______________________ 5. _________________________________________________ $ __________________________

3._________________________________________________	$ ______________________ 6. _________________________________________________ $ __________________________

Homeowner/Renter Insurance Company		Policy or ID #	Deductible
			$

Auto/Other Insurance Company		Policy or ID #	Deductible
			$

— If there were no injuries and you are only asking for essential personal property benefits, skip to 15. —

7Tell us about the victim’s or the parent’s employment and insurance for Lost Wages.

If you do not want us to contact your employer, you cannot ask to be reimbursed for Lost Wages. (Skip to 8.)

Was the victim/parent of hospitalized minor victim employed when the crime happened?

Yes

No (If No, skip to 8.)

Did the victim/parent of hospitalized minor victim miss work because of the crime?					Yes	No
Was the victim/parent self-employed?		Yes	No (If Yes, attach copies of last year’s federal tax return and all schedules.)
Employer’s Name, Address, and Phone #:
					(	)
Employer	Street	City	State	Zip Code		Phone #
Other Employer’s Name, Address, and Phone #:
					(	)
Employer	Street	City	State	Zip Code		Phone #
Name, Address, and Phone # of doctor who certified victim could not go to work:
					(	)
Doctor	Street	City	State	Zip Code		Phone #

Tell us about any insurance company that will cover the victim’s lost time at work. (If none, write “None” below and skip to 8.)

		Policy or ID # or “None”			Policy or ID # or “None”
1.	Unemployment Insurance		5.	Workers’ Compensation

2.	Disability Insurance		6.	Other insurance

3.	Pension Plan		7.	Social Security Benefits (ssn	SSN
			required)		__ __ __ - __ __ - __ __ __ __

4.	Other insurance		8.	SSI Benefits (ssn required)	SSN
					__ __ __ - __ __ - __ __ __ __

8If the victim died, fill out below if you have any burial expenses. (If not, skip to 9.)

Also, attach a copy of the funeral home contract, other bills for burial expenses, and a photocopy of the Death Certificate, if you have them.

Name of Funeral Home:			Phone #: (		)
Address:
	Street	City		State	Zip Code
Rev. December 2013					Page 2 of 4

9If the victim was injured or died because of this crime, fill out below.

Describe the victim’s injuries, briefly:

_________________________________________________________________________________________________________________________

Did the victim receive any medical treatment?		Yes	No (If No, skip to section10.)
Tell us about the health professionals who treated the victim for injuries related to this crime:
	Full Name	Complete Address		Phone #
First Hospital	___________________________________	______________________________________________________________________		(______) ____________________
Other Hospital	___________________________________	______________________________________________________________________		(______) ____________________
First Doctor
(not in hospital)	___________________________________	______________________________________________________________________		(______) ____________________
Other Doctor	___________________________________	______________________________________________________________________		(______) ____________________
First Dentist	___________________________________	______________________________________________________________________		(______) ____________________
Victim’s Counselor	___________________________________	______________________________________________________________________		(______) ____________________

10Tell us about the victim’s dependents or others who depended on the victim for support. (If none, skip to 11.)

	Name	Social Security #	Date of Birth	Relationship to Victim
Dependent		__ __ __ - __ __ - __ __ __ __
	Address			Are you the legal
				guardian?	Yes	No

Other	Name	Social Security #	Date of Birth	Relationship to Victim
Other		__ __ __ - __ __ - __ __ __ __
Dependent		__ __ __ - __ __ - __ __ __ __

	Address			Are you the legal
	Address			Are you the legal
				guardian?	Yes	No

Other	Name	Social Security #	Date of Birth	Relationship to Victim
Other		__ __ __ - __ __ - __ __ __ __
Dependent		__ __ __ - __ __ - __ __ __ __

	Address			Are you the legal
	Address			Are you the legal
				guardian?	Yes	No

If more than 3 dependents, attach a separate sheet and check here:

11 Did anyone besides the victim receive counseling because of this crime? (If no, skip to 12.)

Who received counseling?

Relationship to Victim

Insurance company billed for counseling Policy or ID #

Counselor’s name, address and phone #:

Who else received counseling?

Relationship to Victim

Insurance company billed for counseling Policy or ID #

Counselor’s name, address and phone #:

If more than 2 people received counseling because of this crime, check here and attach a separate sheet to describe.

12List any insurance covering the victim or the victim’s dependents. If no insurance, write “None” below.

If you have applied but are not covered yet, write “Pending” under Policy or ID #.

Policy or ID #

Name of person(s) covered by this insurance:

Primary Insurance Company

Major Medical Insurance Company

Other Insurance (Union, Dental, Vision, etc.)

Medicare

Medicaid

Workers’ Compensation

Auto Insurance

Other insurance

Rev. December 2013

Page 3 of 4

How to Edit Ovs Application Form Online for Free

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Step 1: Click on the "Get Form" button above. It is going to open our editor so that you could begin completing your form.

Step 2: As you start the tool, you will get the document prepared to be filled out. Besides filling out different fields, you can also perform various other actions with the file, such as writing custom words, changing the original textual content, inserting images, affixing your signature to the PDF, and a lot more.

Be attentive when completing this document. Ensure that every single blank is done properly.

1. Whenever completing the claim application, be sure to incorporate all essential blanks in its corresponding section. It will help hasten the process, which allows your details to be handled quickly and accurately.

Stage # 1 for filling out claim ovs form

2. Right after finishing the previous section, go to the next step and fill out the essential particulars in all these blank fields - OVS VAP ID, Program NamePhone, Advocate NameEmail, Victim Assistance Program Use Only, Tell us about the victim Last Name, First Name, Social Security, Check here if you do not have one, Date of Birth, Mailing Address Street, Apt or PO Box, City, County, State or Foreign Country, and Zip Code.

Mailing Address Street, Advocate NameEmail, and Tell us about the victim Last Name in claim ovs form

3. This 3rd part is generally rather straightforward, Check here if you do not have one, Mailing Address Street, Apt or PO Box, City, County, State or Foreign Country, Zip Code, What is your relationship to the, Parent, Spouse, Child, Legal Guardian, Attorney, Other Explain, and Tell us about the crime Check only - all these fields must be filled out here.

Find out how to complete claim ovs form step 3

4. The following section will require your attention in the subsequent areas: County where crime happened Date, Rev December, and Page of. Make sure you fill in all of the required details to move further.

County where crime happened Date, Page of, and Rev December of claim ovs form

You can easily get it wrong when filling out your County where crime happened Date, and so ensure that you look again before you decide to finalize the form.

5. The pdf has to be wrapped up by filling in this segment. Here there's an extensive listing of form fields that require specific information for your form submission to be accomplished: Tell us about the suspect Suspects, Has the suspect been arrested for, Yes Yes, No No, Not Yet, Yes Yes Yes Yes Amount, No No If Yes attach a copy No, Not Yet, Not Yet, NOTE If you are eligible for, Tell us about your expenses, Death Claim Only, Loss of Support, Lost Wages DV Shelter, and Personal Transportation.

Step 3: Right after proofreading the form fields you have filled out, click "Done" and you're done and dusted! Acquire the claim application after you join for a free trial. Instantly view the pdf form in your FormsPal account, along with any modifications and adjustments being conveniently preserved! FormsPal guarantees your information privacy via a protected method that in no way records or distributes any kind of personal information involved. Be assured knowing your documents are kept confidential when you work with our services!

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