Form 812-1321 "Application for Crime Victims' Compensation" - Missouri

What Is Form 812-1321?

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

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Missouri Department of Public Safety;
  • 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 812-1321 by clicking the link below or browse more documents and templates provided by the Missouri Department of Public Safety.

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Download Form 812-1321 "Application for Crime Victims' Compensation" - Missouri

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SUBMIT
Reset Form
Print Form
FOR OFFICE USE ONLY
Claim No.
MISSOURI DEPARTMENT OF PUBLIC SAFETY
APPLICATION FOR CRIME VICTIMS’ COMPENSATION
1. Type or Print clearly in ink.
:
INSTRUCTIONS
2. Last page of this form must be signed by claimant.
3. If victim is a minor or an incompetent person, application MUST be made by a parent or guardian.
4. If a question is NOT APPPLICABLE, answer with N/A.
MAILING ADDRESS
TELEPHONE NUMBER
RELAY MISSOURI
CRIME VICTIMS’ COMPENSATION PROGRAM
573-526-6006
1-800-735-2966 (TDD)
P.O. BOX 749, JEFFERSON CITY, MISSOURI 65102-0749
1-800-347-6881
1-800-735-2466 (VOICE)
How did you find out about the Crime Victims’ Compensation Program?
Police
__________)
Victim Assistance
________)
Prosecutor (Agency Code __________)
(Agency Code
(Agency Code
Hospital
Funeral Home
Friend/Family
SECTION I — PRIMARY VICTIM INFORMATION
Name of Victim (Last, First and Middle)
Social Security Number
Current Street Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Country of Birth – National Origin*
Is Victim Deceased?
Yes
No
Birthdate
Age
Sex
Transgender
Marital Status
Married
Divorced
Male
Single
Female
Separated
Widowed
Race (Check One) *
Handicapped Prior to Crime*
Yes
No (
)
Explain
American Indian/Alaska Native
Hispanic/Latino
Other: ____________
Asian
Multiple Races
White/Caucasian
Date Crime Occurred:
Black/African American
Native Hawaiian/Pacific Islander
SECTION II — CLAIMANT INFORMATION
Complete this section if someone other than the victim is filing claim (i.e. parent/legal guardian).
Name of Claimant (Last, First and Middle)
Social Security Number
Street Address
City
State
Zip Code
Relationship to Victim
Home Telephone Number
Work Telephone Number
Was victim living with you at the time
of the crime?
Yes
No
Birthdate
Age
Sex
Transgender
Marital Status
Married
Divorced
Male
Female
Single
Separated
Widowed
Race (Check One) *
Black/African American
Multiple Races
Other: __________________
American Indian/Alaska Native
Asian
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
SECTION III — OTHER COMPENSABLE VICTIM *CHAPTER 595 (If more than one, use additional sheet.)
Name of Other Compensable Victim (Last, First and Middle)
Social Security Number
Current Street Address
City
State
Zip Code
Home/Work Telephone Number
Relationship to Primary Victim
Country of Birth – National Origin*
Handicapped Prior to Crime*
Yes
No
Birthdate
Age
Sex
Marital Status
Transgender
Married
Divorced
Male
Single
Female
Separated
Widowed
Race (Check One) *
Black/African American
Multiple Races
Other: __________________
American Indian/Alaska Native
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Asian
Was the other compensable victim living with the primary victim at the time of the crime? (Chapter 595)
Yes
No
If yes, explain:
* This information is requested solely for compliance with Federal Civil Rights under Section 1407(e) of the Victims of Crimes Act of 1984. It will be
used only for statistical purposes.
812-1321 (10-18)
SUBMIT
Reset Form
Print Form
FOR OFFICE USE ONLY
Claim No.
MISSOURI DEPARTMENT OF PUBLIC SAFETY
APPLICATION FOR CRIME VICTIMS’ COMPENSATION
1. Type or Print clearly in ink.
:
INSTRUCTIONS
2. Last page of this form must be signed by claimant.
3. If victim is a minor or an incompetent person, application MUST be made by a parent or guardian.
4. If a question is NOT APPPLICABLE, answer with N/A.
MAILING ADDRESS
TELEPHONE NUMBER
RELAY MISSOURI
CRIME VICTIMS’ COMPENSATION PROGRAM
573-526-6006
1-800-735-2966 (TDD)
P.O. BOX 749, JEFFERSON CITY, MISSOURI 65102-0749
1-800-347-6881
1-800-735-2466 (VOICE)
How did you find out about the Crime Victims’ Compensation Program?
Police
__________)
Victim Assistance
________)
Prosecutor (Agency Code __________)
(Agency Code
(Agency Code
Hospital
Funeral Home
Friend/Family
SECTION I — PRIMARY VICTIM INFORMATION
Name of Victim (Last, First and Middle)
Social Security Number
Current Street Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Country of Birth – National Origin*
Is Victim Deceased?
Yes
No
Birthdate
Age
Sex
Transgender
Marital Status
Married
Divorced
Male
Single
Female
Separated
Widowed
Race (Check One) *
Handicapped Prior to Crime*
Yes
No (
)
Explain
American Indian/Alaska Native
Hispanic/Latino
Other: ____________
Asian
Multiple Races
White/Caucasian
Date Crime Occurred:
Black/African American
Native Hawaiian/Pacific Islander
SECTION II — CLAIMANT INFORMATION
Complete this section if someone other than the victim is filing claim (i.e. parent/legal guardian).
Name of Claimant (Last, First and Middle)
Social Security Number
Street Address
City
State
Zip Code
Relationship to Victim
Home Telephone Number
Work Telephone Number
Was victim living with you at the time
of the crime?
Yes
No
Birthdate
Age
Sex
Transgender
Marital Status
Married
Divorced
Male
Female
Single
Separated
Widowed
Race (Check One) *
Black/African American
Multiple Races
Other: __________________
American Indian/Alaska Native
Asian
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
SECTION III — OTHER COMPENSABLE VICTIM *CHAPTER 595 (If more than one, use additional sheet.)
Name of Other Compensable Victim (Last, First and Middle)
Social Security Number
Current Street Address
City
State
Zip Code
Home/Work Telephone Number
Relationship to Primary Victim
Country of Birth – National Origin*
Handicapped Prior to Crime*
Yes
No
Birthdate
Age
Sex
Marital Status
Transgender
Married
Divorced
Male
Single
Female
Separated
Widowed
Race (Check One) *
Black/African American
Multiple Races
Other: __________________
American Indian/Alaska Native
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Asian
Was the other compensable victim living with the primary victim at the time of the crime? (Chapter 595)
Yes
No
If yes, explain:
* This information is requested solely for compliance with Federal Civil Rights under Section 1407(e) of the Victims of Crimes Act of 1984. It will be
used only for statistical purposes.
812-1321 (10-18)
SECTION IV — CRIME INFORMATION
Was a Report Filed?
Yes
No
Type of Crime:
Child Abuse
Domestic Violence
Assault
Sexual Assault
Homicide
DWI*
Involuntary Manslaughter*
Robbery With Injury
Hit & Run*
Other (Explain:) ___________________________________________________________
(* Be Sure To Complete Insurance Under Section VII)
Brief Description of Crime:
Date Crime Occurred
Date Crime Was Reported
Has Arrest Been Made?
Have Charges Been Filed?
Yes
No
Yes
No
Unknown
Place of Crime: Street Address
City/State
County
Name and Address of Agency Incident Reported To
Name of Investigating Officer(s)
Who Committed the Crime? (If Known)
Police Report Number
Docket Number
Did victim know the person who committed the crime?
Yes
No If Yes, in what way? ___________________________________________
Was victim related to the person who committed the crime?
Yes
No If Yes, in what way? _______________________________________
Was victim living in the same household as the offender at the time of the crime?
Yes
No
If Yes, is victim still living in the same house as offender? ________________________________________________________________________
SECTION V — MEDICAL (INCLUDING PSYCHOLOGICAL) EXPENSES
Will there be more bills?
Enter below all expenses for service rendered as a result of this crime.
Yes
No
(Attach all bills available.)
Name of Doctor, Hospital or
Account
Street Address
City
State
Zip Code
Other Provider of Service
Number
SECTION VI — FUNERAL EXPENSES (Attach Copy of Death Certificate and Funeral Bill)
Will dependent(s) receive funeral benefits from the following?
Social Security
Workers’ Compensation
Life Insurance
Other (Specify)
$
$
$
$
Name of Funeral Home
Street Address
City
State
Zip Code
Amount of Funeral and Burial Expenses
$
If Yes, by whom?
Relationship to Victim
Have Burial Expenses Been Paid?
Yes
No
City
State
Zip Code
Will dependent(s) receive any accident or life insurance?
Yes
No
If yes, complete the following:
Name of Beneficiary
Street Address
City
State
Zip Code
Phone (If Known)
812-1321 (10-18)
SECTION VII — INSURANCE AND OTHER COLLATERAL SOURCE INFORMATION
Indicate below if any sources are paying or will pay any of the above expenses.
Source Type:
Health Insurance/HMO/PPO
Veterans Administration
Armed Services (TRICARE)
Life Insurance
Auto Insurance
Medicare
Medicaid No. ________________________________
Workers’ Compensation No. ___________________________
Provide the following information for each source. (If more than one source is paying, provide additional information on separate sheet.)
Insurance Name
Policy Number
Street Address
City
State
Zip Code
Name of Policy Holder
Social Security Number of Policy Holder
Effective Date of Policy / Coverage
AUTO/MOTORCYCLE INSURANCE INFORMATION — COMPLETE THIS SECTION ONLY FOR MOTOR VEHICLE CLAIM
Does convicted operator have liability insurance coverage on
If yes, enter name of carrier and policy limits.
auto/motorcycle?
Yes
No
Street Address
City
State
Zip Code
Policy Number
Does the victim have uninsured motorist coverage on
If yes, enter name of carrier and policy limits.
auto/motorcycle?
Yes
No
Street Address
City
State
Zip Code
Policy Number
Has settlement been made with carrier?
If yes, which one? (Attach copy of settlement)
Yes
No
(Fill out if victim was gainfully employed at the time of
SECTION VIII — WAGE LOSS/LOSS OF SUPPORT
the crime and a loss is being claimed.)
Was victim gainfully employed
Is victim applying
Is a dependent applying
at time of crime?
Yes
No
for lost wages?
Yes
No
for loss of support?
Yes
No
Victim’s Employer (at time of Crime)
Telephone Number
Victim’s Employer Address
City
State
Zip Code
If victim was self-employed, submit copies of signed Federal Income Tax returns from the year of the crime and the year preceding the crime.
Victim’s net (take home) earnings or income at time of crime (including tips and bonuses) if time loss or loss of support benefits are claimed:
$ _____________________ per week.
Date left work due to crime: (Month, Day, Year) ____________________________________________________________________________
Date returned to work: (Month, Day, Year) _________________________________________________________________________________
Days off for which victim received compensation in the form of accrued sick/vacation leave. ____________________________________________
Was the crime work-related?
Yes
No
If Yes, has the victim applied for Workers’ Compensation or other employment benefits?
Yes
No
If Yes, please describe:
Are you receiving or have you received accident or disability benefits from your employer as a result of this injury?
Yes
No
If Yes, please describe.
SECTION IX — OTHER INFORMATION
Is the victim or claimant considering a civil action against the offender or some other third party for damages claimed herein?
Yes
No
If Yes, please provide the name and mailing address of attorney who will handle the civil action:
RESTITUTION
If the court has ordered the offender to make restitution to you (pay you back), complete the following:
Restitution Order Date _________________________
Court ________________________________________ Amount $ __________________
Judge _______________________________________ How Is It To Be Paid? ______________________________________________________
812-1321 (10-18)
ATTORNEY INFORMATION
It is not necessary to retain an attorney; however, if claimant wishes to be represented by an attorney in applying for benefits under Crime Victims’
Compensation, please complete the following. Attorneys are entitled to up to 15% of any award issued. The attorney will need to file an entry of
appearance.
Attorney’s Name (Last, First, MI)
Telephone Number
Address
City
State
Zip Code
Signature of Attorney (if representing claimant in Crime Victims’ claim)
Date
AUTHORIZATION FOR RELEASE OF INFORMATION TO CONDUCT AN INVESTIGATION, TO
MAKE PAYMENTS DIRECTLY TO SUPPLIERS AND ASSIGNMENT OF SUBROGATION RIGHTS
I give permission to any attorney, hospital, funeral home, doctor, law enforcement agency, insurance company,
employer, welfare or social agency, or any federal, state or local government agency to release all records and
information that will help the Missouri Crime Victims’ Compensation Program to process my claim for compensation, to
allow copies of such records to be made and to answer any questions made by or on behalf of the Missouri Crime
Victims’ Compensation Program.
I understand that after receiving this application, the Missouri Crime Victims’ Compensation Program will investigate the
truth of the information provided as well as other matters regarding this claim; and I consent to such investigation. This
authorization is valid for three years from the date given below.
I acknowledge and agree that all or any part of any compensation awarded may be paid directly to any supplier of
goods or services on my behalf.
I further acknowledge and agree that the State of Missouri is subrogated, to the extent of any compensation awarded to
me, to all the claimant’s rights to recover benefits or advantages for economic loss from a source which is, or if readily
available to the victim or claimant would be, a collateral source, and I hereby assign such rights to the State of Missouri
so that it may protect its subrogation rights, and agree to assist the state in pursuing its subrogation rights.
I agree to notify the Department if I retain an attorney to represent me in a lawsuit related to this crime. I also agree to
notify the Department: 1) in the event I receive restitution payments from the offender, or 2) in the event I initiate any
legal proceeding or negotiations to recover damages related to the crime upon which this claim is based.
I certify that I have read and understand the statements above; and that the information I have given is true and correct
to the best of my knowledge and belief and that these benefits will be denied if any such statements are not true.
Signature of Claimant
Date
(If the victim is under 18 years of age, this application must be signed by the parent or legal guardian whose name appears in “Section II — Claimant
Information”).
812-1321 (10-18)