Form JD-VS-35 "Crime Disclosure" - Connecticut

What Is Form JD-VS-35?

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 December 1, 2018;
  • 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-35 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-35 "Crime Disclosure" - Connecticut

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CRIME DISCLOSURE
STATE OF CONNECTICUT
OFFICE OF VICTIM SERVICES
JD-VS-35 Rev. 12-18
C.G.S. § 54-209(d) and (e)
JUDICIAL BRANCH
www.jud.ct.gov/crimevictim/
Instructions
1. Print or type the information requested.
2. Please send to: Office of Victim Services, 225 Spring Street, 4th Floor, Wethersfield, CT, 06109
or Fax to: 860-263-2780 or e-mail to: OVSCompensation@jud.ct.gov.
Name of victim (first, middle, last)
Date of birth (mm/dd/yyyy)
Name of claimant or person filing for claimant
Claim number
Claims examiner
1. Did the victim disclose that she or he was a victim of a crime in Connecticut?
Yes (go to question 2)
No (skip to question 7)
2. Check the type of crime (you may check more than 1 box):
sexual assault
domestic violence
other:
human trafficking
child abuse
3. Did the victim suffer a physical injury?
Yes
No
Don't know
4. Did the victim suffer an emotional injury from a threat of either physical injury or death and received treatment?
Yes
No
Don't know
5. Describe the incident and any physical or emotional injuries:
6. Date of incident:
City/town of incident:
Date incident disclosed to you:
7. Check your profession:
To be eligible for victim compensation, victims must report the crime to police; however, state law allows victims of certain crimes to
disclose the crime to 1 of the professionals listed below instead of reporting to police. Victims of domestic violence may only disclose to
a certified sexual assault counselor or a certified domestic violence counselor instead of reporting to police.
alcohol and drug counselor
police officer
clinical social worker
psychologist
counselor
resident physician or intern at a Connecticut hospital
emergency medical services provider
school guidance counselor
employee of Department of Children and Families
school principal
marriage and family therapist
school teacher
mental health professional
sexual assault or domestic violence counselor ( must be certified )
nurse (advanced practice, practical, or registered)
surgeon
physician or physician assistant
Name of the person completing form (print first, middle, last)
Title
Provider license number, if applicable
Name of agency
Agency address, city, state zip
Telephone number
Signature of person completing form
Date
Thank you for helping OVS in its efforts to provide financial compensation to eligible crime victims.
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.
Print Form
Reset Form
CRIME DISCLOSURE
STATE OF CONNECTICUT
OFFICE OF VICTIM SERVICES
JD-VS-35 Rev. 12-18
C.G.S. § 54-209(d) and (e)
JUDICIAL BRANCH
www.jud.ct.gov/crimevictim/
Instructions
1. Print or type the information requested.
2. Please send to: Office of Victim Services, 225 Spring Street, 4th Floor, Wethersfield, CT, 06109
or Fax to: 860-263-2780 or e-mail to: OVSCompensation@jud.ct.gov.
Name of victim (first, middle, last)
Date of birth (mm/dd/yyyy)
Name of claimant or person filing for claimant
Claim number
Claims examiner
1. Did the victim disclose that she or he was a victim of a crime in Connecticut?
Yes (go to question 2)
No (skip to question 7)
2. Check the type of crime (you may check more than 1 box):
sexual assault
domestic violence
other:
human trafficking
child abuse
3. Did the victim suffer a physical injury?
Yes
No
Don't know
4. Did the victim suffer an emotional injury from a threat of either physical injury or death and received treatment?
Yes
No
Don't know
5. Describe the incident and any physical or emotional injuries:
6. Date of incident:
City/town of incident:
Date incident disclosed to you:
7. Check your profession:
To be eligible for victim compensation, victims must report the crime to police; however, state law allows victims of certain crimes to
disclose the crime to 1 of the professionals listed below instead of reporting to police. Victims of domestic violence may only disclose to
a certified sexual assault counselor or a certified domestic violence counselor instead of reporting to police.
alcohol and drug counselor
police officer
clinical social worker
psychologist
counselor
resident physician or intern at a Connecticut hospital
emergency medical services provider
school guidance counselor
employee of Department of Children and Families
school principal
marriage and family therapist
school teacher
mental health professional
sexual assault or domestic violence counselor ( must be certified )
nurse (advanced practice, practical, or registered)
surgeon
physician or physician assistant
Name of the person completing form (print first, middle, last)
Title
Provider license number, if applicable
Name of agency
Agency address, city, state zip
Telephone number
Signature of person completing form
Date
Thank you for helping OVS in its efforts to provide financial compensation to eligible crime victims.
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.
Print Form
Reset Form