Form JD-VS-8SB "Survivor Benefits - Application" - Connecticut

What Is Form JD-VS-8SB?

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 October 1, 2017;
  • 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-8SB 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-8SB "Survivor Benefits - Application" - Connecticut

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SURVIVOR BENEFITS
APPLICATION
JD-VS-8SB 10/17
We understand this is a difficult time for you and your family. 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
Name of victim (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Gender:  female  male  other
SECTION 2 –
CLAIMANT INFORMATION
The person who has expenses because of the crime.
How is the claimant related to the victim?
 child
 spouse
 parent
 grandchild
 grandparent
 spouse’s parent
 stepparent
 brother
 sister
 half-brother
 half-sister
 step-child
 adopted child  party to a civil union
 aunt
 uncle
 niece
 nephew
 other
Name of claimant (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone
Cell phone
Email
Gender:
 female
 male
 other
Primary language spoken
FOR OFFICE USE ONLY
Claim Number
Claims Examiner
SURVIVOR BENEFITS
APPLICATION
JD-VS-8SB 10/17
We understand this is a difficult time for you and your family. 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
Name of victim (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Gender:  female  male  other
SECTION 2 –
CLAIMANT INFORMATION
The person who has expenses because of the crime.
How is the claimant related to the victim?
 child
 spouse
 parent
 grandchild
 grandparent
 spouse’s parent
 stepparent
 brother
 sister
 half-brother
 half-sister
 step-child
 adopted child  party to a civil union
 aunt
 uncle
 niece
 nephew
 other
Name of claimant (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone
Cell phone
Email
Gender:
 female
 male
 other
Primary language spoken
FOR OFFICE USE ONLY
Claim Number
Claims Examiner
SECTION 3 –
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
Cell phone
Email
Gender:
 female
 male
 other
Primary language spoken
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
Address
City
State
Zip
Work telephone
Fax number
Email
Juris number
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
Cell phone
Email
SECTION 6 –
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
How did you find out about the Victim Compensation Program:
SECTION 7 –
CRIME INFORMATION
Date of crime
Address and city where crime happened
Type of crime:  homicide  driving under the influence (dui)
 evading (hit and run)
 other (briefly describe the crime):
Date crime reported to police
Police department crime reported to
Name of officer investigating the crime
Police report number
SECTION 8 –
OFFENDER INFORMATION
Was someone arrested for the crime?  yes
 no
 don’t know
Name of person arrested, if known
Did the offender go to court?
 yes
 no
 don’t know
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 9 –
CRIMES INVOLVING A VEHICLE
Fill out this section if the crime involved a vehicle (for example, a car, motorcycle, or a boat). You must check at least
1 of the following:
 I filed a claim with the victim’s insurance
I filed a third-party claim with:
 the other driver’s insurance
 a relative’s insurance
 my employer’s insurance
 I did not file an insurance claim. Please explain why
Did you receive an insurance settlement?
 yes
 no
 settlement pending
If you filed an insurance claim or have insurance available to you, please fill out the information below:
Insurance company name
Address (street, city, state, zip)
Policy holder’s name (first, middle, last)
Policy number
Telephone
If the other driver was driving while under the influence of alcohol or drugs, did you or will you file a civil lawsuit against
the place of business or person that served the alcohol?
 yes
 no
 don’t know
SECTION 10 –
CRIME-RELATED EXPENSES AND FINANCIAL RESOURCES
(continued)
CRIME SCENE CLEAN-UP EXPENSES (Maximum benefit $1,000)
Please fill out this section if you paid all or part of the crime scene clean-up expenses and provide copies of bills and
receipts, if available. Expenses may include biohazard cleaning, replacing or repairing damaged locks, windows, doors,
and alarm systems.
Provider Name
Address (street, city, state, zip)
Telephone
Financial Resources
Insurance Company
Policy Number
Telephone
 Homeowners’ Insurance
 Renters’ Insurance
 Vehicle Insurance
(for crimes involving vehicles)
EXPENSES TO ATTEND ADULT COURT PROCEEDINGS
Please fill out this section if you have or will have expenses to attend adult court proceedings. The relatives of the
victim that are eligible for this benefit include the victim’s child (natural, adopted, step), spouse, parent, spouse’s
parents, grandchild, grandparent, stepparent, brother and sister (natural and half), aunt, uncle, niece, and nephew.
Please check the type of expenses and losses you have or will have to attend adult court proceedings:
 travel expenses (includes mileage reimbursement)
 lost wages (please fill out the information about your employer. OVS will contact your employer for the dates absent
and salary and benefit information. If you have a concern about this, please call us.)
Please list the dates you attended or will attend court proceedings:
Name of employer
Contact name
Telephone
Address
City
State
Zip
Hours worked per week
Wages per hour
Tips, bonuses per week
LOSS OF SUPPORT
Please list all of the victim’s financial dependents (spouse and children). For a child, attach a copy of the child’s birth
certificate. For a spouse, attach a copy of the marriage certificate (attach additional pages, if needed).
Dependent’s
Address
Relationship
Birth date
Parent or
name
(street, city, state, zip)
to victim
(mm/dd/yyyy)
guardian
SECTION 10 –
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 11 and sign the application)
FUNERAL EXPENSES (Maximum benefit $5,000)
Please fill out this section if you have or will have funeral expenses and attach a copy of the death certificate, if available.
Please also include copies of receipts showing your payments or an itemized bill from the funeral home.
Was an estate opened in probate court?
 yes
 no
 don’t know
If you checked yes above, are you the administrator or the executor of the estate?
 yes (please attach a copy of the probate court’s appointment order)
 no (please apply to the estate for reimbursement of funeral expenses)
Name of funeral home
Contact name
Telephone
Address
City
State
Zip
Financial Resources
Insurance Company
Member Number
Telephone
 Burial or Funeral Insurance
 Department of Social Services
(funeral)
 Vehicle Insurance
(for crimes involving vehicles)
 Workers’ Compensation
(for crimes at work)
 Donations
(example: GoFundMe)
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.
Provider Name
Address (street, city, state, zip)
Telephone
Financial Resources
Insurance Company
Member Number
Telephone
 Dental Insurance
 Department of Social Services
(Medicaid/Husky)
 Health Insurance
(primary)
 Health Insurance
(secondary)
 Medicare
 Supplemental Insurance
(accident/illness)
 Vehicle Insurance
(for crimes involving vehicles)
 Veterans Health Administration
 Workers’ Compensation
(for crimes at work)
 Donations
(example GoFundMe)
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