Form JD-VS-8EI "Emotional Injury Application" - Connecticut

What Is Form JD-VS-8EI?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2019;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-VS-8EI by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-VS-8EI "Emotional Injury Application" - Connecticut

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EMOTIONAL INJURY
APPLICATION
JD-VS-8EI Rev. 6/19
We are here to help. If you have any questions about filling out this application or the Victim Compensation Program,
please call us at 1-888-286-7347. Please know that it is important that you tell us if your contact information changes.
If we cannot reach you, you may miss important deadlines set by state law or your claim may be closed.
SECTION 1 –
VICTIM INFORMATION
The person who was emotionally injured because of the crime.
Name of victim (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone number
Cell phone number
Email
Gender:
 female  male  other
Primary language spoken
SECTION 2 –
PARENT/LEGAL GUARDIAN/CONSERVATOR INFORMATION
This section is for parents or legal guardians of children under 18 years old and legal guardians or conservators
for an incapacitated adult.
 parent
 adoptive parent
Relationship:
 legal guardian
 conservator
Name of parent/legal guardian/conservator (first, middle, last)
Address
City
State
Zip
Daytime phone number
Cell phone number
Email
Gender:
 female
 male
 other
Primary language spoken
SECTION 3 –
STATISTICAL INFORMATION
It is your choice to answer these questions. This information is used in state and federal reports.
Would you describe the victim as:
 american indian/alaska native
 asian
 black/african american
 hispanic/latino/latina
 native hawaiian/other pacific islander
 white non-latino/caucasian
 other race
Was the victim disabled before the crime?
 yes
 no
 don’t know
Was the victim disabled after the crime?
 yes
 no
 don’t know
How did you find out about the Victim Compensation Program:
FOR OFFICE USE ONLY
Claim Number
Claims Examiner
EMOTIONAL INJURY
APPLICATION
JD-VS-8EI Rev. 6/19
We are here to help. If you have any questions about filling out this application or the Victim Compensation Program,
please call us at 1-888-286-7347. Please know that it is important that you tell us if your contact information changes.
If we cannot reach you, you may miss important deadlines set by state law or your claim may be closed.
SECTION 1 –
VICTIM INFORMATION
The person who was emotionally injured because of the crime.
Name of victim (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone number
Cell phone number
Email
Gender:
 female  male  other
Primary language spoken
SECTION 2 –
PARENT/LEGAL GUARDIAN/CONSERVATOR INFORMATION
This section is for parents or legal guardians of children under 18 years old and legal guardians or conservators
for an incapacitated adult.
 parent
 adoptive parent
Relationship:
 legal guardian
 conservator
Name of parent/legal guardian/conservator (first, middle, last)
Address
City
State
Zip
Daytime phone number
Cell phone number
Email
Gender:
 female
 male
 other
Primary language spoken
SECTION 3 –
STATISTICAL INFORMATION
It is your choice to answer these questions. This information is used in state and federal reports.
Would you describe the victim as:
 american indian/alaska native
 asian
 black/african american
 hispanic/latino/latina
 native hawaiian/other pacific islander
 white non-latino/caucasian
 other race
Was the victim disabled before the crime?
 yes
 no
 don’t know
Was the victim disabled after the crime?
 yes
 no
 don’t know
How did you find out about the Victim Compensation Program:
FOR OFFICE USE ONLY
Claim Number
Claims Examiner
SECTION 4 –
ATTORNEY REPRESENTATION
You do not need an attorney to receive victim compensation. If you do have an attorney, please check if the attorney is
helping you with your claim, a civil lawsuit, or both and provide the attorney’s contact information.
 Representing me on this application
 Representing me in a civil lawsuit
Name of attorney (first, middle, last)
Name of firm
Juris number
Address
City
State
Zip
Work phone number
Fax
Email
SECTION 5 –
PERMISSION TO CONTACT OR SPEAK WITH ANOTHER PERSON
Please check if you are giving OVS permission to contact someone if we can’t reach you, permission to speak with
someone about your claim, or both, and provide that person’s contact information.
 Permission to contact, if OVS can’t reach me
 Permission to speak with about my claim
Name of person (first, middle, last)
How do you know this person?
Address
City
State
Zip
Daytime phone number
Cell phone number
Email
SECTION 6 –
CRIME INFORMATION
If the crime involved human trafficking, please do not fill out this section but answer the questions in Section 6a.
Date(s) of crime
Address and city where crime happened
Type of crime:
 threat of death  threat of physical injury  robbery  kidnapping  child pornography
 unlawful sharing of an intimate image  voyeurism  stalking  child witness to domestic violence
 other
Briefly describe the crime:
Date crime reported to police:
Was the crime reported within 5 days?
 yes  no (if no, please explain):
Police department
Name of officer investigating the crime
Police report number
If the crime was domestic violence and not reported to police, please check which professional you told about the crime:
 judge (if the judge gave you a restraining or civil protection order, please attach a copy of the application or affidavit.)
 certified domestic violence counselor
 certified sexual assault counselor
 other
SECTION 6a –
HUMAN TRAFFICKING CRIMES
Date(s) of crime
Address and city where crime happened
Type of crime:
 forced labor
 other
Please check which professional you told about the crime:
 judge (if the judge gave you a restraining or civil protection order, please attach a copy of the application or affidavit.)
 certified sexual assault or domestic violence counselor  medical professional
 mental health professional
 police  Department of Children and Families employee
 school professional
 other
Name of the person you told about the crime
Title
Date you told that person
Address (street, city, state, zip)
Phone number
SECTION 7 –
OFFENDER INFORMATION
Was someone arrested for the crime?
 yes
 no
 don’t know
Name of person arrested, if known
 don’t know
 yes
 no
Did the offender go to court?
If yes, city where courthouse is located
Docket number, if known:
Did the court order the offender to pay for your crime-related expenses (restitution)?
 yes
 no
 don’t know
SECTION 8 –
CRIME-RELATED EXPENSES AND FINANCIAL RESOURCES
Please check the box next to the compensation benefit you are applying for, the boxes next to the financial resources you
have available to you, and fill out the information requested. You must contact us if any of the financial resources not
checked become available to you. If you do not have any crime-related expenses at this time, it is important that you still
submit the application in case you need financial help in the future.
NO EXPENSES AT THIS TIME (please skip to Section 9 and sign the application)
MEDICAL, MENTAL HEALTH, DENTAL, AND PRESCRIPTION EXPENSES
Please list the names of all providers who treated you and provide copies of crime-related bills, prescription printouts
for co-pay amounts, and insurance benefit statements, if available.
Address (street, city, state, zip)
Provider Name
Phone Number
DO YOU OR WILL YOU HAVE CRIME-RELATED BILLS PAID BY 1 OR MORE OF THESE FINANCIAL RESOURCES?
Insurance Company
Member Number
Phone Number
 Dental Insurance
 Department of Social Services
(Medicaid/Husky)
 Health Insurance
 Medicare
CRIME SCENE CLEANUP AND SECURITY SYSTEM EXPENSES (maximum benefit $1,000)
Please fill out this section if you paid all or part of the expenses. Provide a copy of a note from your medical or mental
health provider that states these expenses are part of your treatment and a copy of bills and receipts, if available.
Expenses may include replacing or repairing damaged locks, windows, doors, and installation of security systems.
Phone Number
Provider Name
Address (street, city, state, zip)
SECTION 9 –
STATEMENT OF FACTS AND AUTHORIZATION
I certify that the information in this application for victim compensation is true to the best of my knowledge, information,
and belief. I give permission to any hospital, physician(s) or other person(s) who attended, examined, or gave services to me
or to any minor child or incapacitated adult for whom I am the parent, legal guardian, or conservator and have the authority
to act on his or her behalf; to my employer(s) and the employer(s) of the person I am acting on behalf of; any police or other
municipal authority or agency, or public authorities including state and federal revenue services, any insurance company or
organization having knowledge of the incident to give to the Office of Victim Services (OVS) or its representative any and all
information regarding the incident leading to the victim’s emotional injuries and this application for victim compensation.
A copy of this authorization will be considered as effective and valid as the original.
I give permission to OVS to disclose any information in its records, including confidential information, to the offices of the
Court Support Services Division, the State’s Attorney, the Attorney General, the Office of the United States Attorneys, and to
private attorneys retained by OVS or by me, and to communicate freely with them when necessary (Section 54-208(e),
54-212, and 54-215 of the Connecticut General Statutes).
I understand that I must notify OVS if I file a lawsuit against whoever is responsible for the injury for which OVS paid the
compensation within 30 days of the filing of the action in court. If I recover money from the lawsuit, either by a judgment
or by settlement, I understand that OVS is entitled by state law to 2/3 of the amount OVS paid. (Section 54-212 of the
Connecticut General Statutes). If I have filed a lawsuit, I agree to provide a copy of the writ, summons, and complaint to
OVS immediately.
I understand that OVS will have the right to bring a lawsuit in my name against whoever is responsible for the injury for
which the money was paid. I also understand that if OVS recovers money from the lawsuit, OVS is entitled by state law to
keep 2/3 of the amount paid, plus costs and interest. OVS will pay me any balance over that amount (Section 54-212 of the
Connecticut General Statutes).
I understand that if I or the person I am filing on behalf of receives money from any other sources, including payments from
state or municipal agencies, insurance benefits, or workers’ compensation because of the incident, OVS is entitled by state
law to 2/3 of the amount OVS paid (Section 54-212 of the Connecticut General Statutes).
I understand that if the court orders restitution to me or to the person I am filing on behalf of for expenses paid by OVS,
OVS is entitled to receive full reimbursement, unless the court orders differently (Section 54-215 of the Connecticut General
Statutes).
I also understand that my providers may be reimbursed directly for debts that I owe.
Applicant signature
Print your name
Date
The adult applicant, the parent/legal guardian/conservator of a minor child (under 18 years old), or the legal guardian/conservator for an
incapacitated adult must sign this application. Applications that are not signed will be returned.
Please mail, fax, or email the completed application to: Office of Victim Services, 225 Spring Street, 4th Floor, Wethersfield,
CT 06109; Fax: 860-263-2780; Email: OVSCompensation@jud.ct.gov
Contact OVS at: 1-888-286-7347 or www.jud.ct.gov/crimevictim/
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA).
If you need a reasonable accommodation, in accordance with the ADA, call OVS at 1-800-822-8428.
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