"Victim Compensation Application" - Delaware

Victim Compensation Application is a legal document that was released by the Delaware Department of Justice - a government authority operating within Delaware.

Form Details:

  • Released on January 1, 2010;
  • The latest edition currently provided by the Delaware Department of Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Justice.

ADVERTISEMENT
ADVERTISEMENT

Download "Victim Compensation Application" - Delaware

385 times
Rate (4.8 / 5) 23 votes
CLAIM FORM
Complete and submit to:
Delaware Victims’ Compensation Assistance Program
900 North King St., Suite 4
Wilmington, DE 19801
http://www.attorneygeneral.delaware.gov/VCAP
Please contact the DE VCAP if you need assistance completing this form (Phone)302.255.1770 (Fax)302.577.1326
SECTION 1. VICTIM INFORMATION SECTION
Name of person injured or killed as the result of the violent crime. If there was more than one victim,
complete a separate claim form for each victim.
Victim’s Name (last, first, m.i.)
Date of Birth (MM/DD/YY)
Social Security Number
/
/
Gender
Race (optional)
Is Victim Deceased?
Male
Female
Asian/Pacific Island
American Indian/Alaska Native
Black
Yes
No
Hispanic
White
Other ___________________
Street Address (including apartment #)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
(
)
(
)
(
)
Who referred you to the compensation program?
Contact Person:______________________________________________________________________
Hospital
Police Agency
Prosecutor
Victim Services Police
Victim Services DOJ
Poster/Brochure/Advertisement
Public Service Announcement
Other:______________________
SECTION 2. CLAIMANT INFORMATION
Name of person filing on behalf of a deceased victim, minor victim, or an incapacitated adult victim.
Claimant’s Name (last, first, m.i.)
Date of Birth (MM/DD/YY)
Social Security Number
/
/
Gender
Relationship to Victim
Male
Female
Parent
Spouse/Partner
Former Spouse/Partner
Child
Sibling
Grandparent
Other __________________
Street Address (including apartment #)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
(
)
(
)
(
)
SECTION 3. CRIME INFORMATION
Date of Crime
Date Reported to Police
Name of Suspect
/
/
/
/
Relationship of suspect to victim: _______________________________________________________________________________________________
Name of Police Department Investigating Crime
Police Complaint Number
Investigating Officer’s Name
Location of Crime (address)
City
State
Zip Code
Type of Crime: (please check one)
Assault
DWI/DUI
Homicide/Murder
Child Sexual Abuse
Child Physical Abuse
Stalking
Kidnapping
Arson
Domestic Abuse
Adult Sexual Abuse
Robbery
Burglary
Protection From Abuse (PFA) or PFA ex parte (emergency hearing)
Other
Please specify if other: _______________________________
1
VCAP Claim Form
(1/10)
CLAIM FORM
Complete and submit to:
Delaware Victims’ Compensation Assistance Program
900 North King St., Suite 4
Wilmington, DE 19801
http://www.attorneygeneral.delaware.gov/VCAP
Please contact the DE VCAP if you need assistance completing this form (Phone)302.255.1770 (Fax)302.577.1326
SECTION 1. VICTIM INFORMATION SECTION
Name of person injured or killed as the result of the violent crime. If there was more than one victim,
complete a separate claim form for each victim.
Victim’s Name (last, first, m.i.)
Date of Birth (MM/DD/YY)
Social Security Number
/
/
Gender
Race (optional)
Is Victim Deceased?
Male
Female
Asian/Pacific Island
American Indian/Alaska Native
Black
Yes
No
Hispanic
White
Other ___________________
Street Address (including apartment #)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
(
)
(
)
(
)
Who referred you to the compensation program?
Contact Person:______________________________________________________________________
Hospital
Police Agency
Prosecutor
Victim Services Police
Victim Services DOJ
Poster/Brochure/Advertisement
Public Service Announcement
Other:______________________
SECTION 2. CLAIMANT INFORMATION
Name of person filing on behalf of a deceased victim, minor victim, or an incapacitated adult victim.
Claimant’s Name (last, first, m.i.)
Date of Birth (MM/DD/YY)
Social Security Number
/
/
Gender
Relationship to Victim
Male
Female
Parent
Spouse/Partner
Former Spouse/Partner
Child
Sibling
Grandparent
Other __________________
Street Address (including apartment #)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-Mail Address
(
)
(
)
(
)
SECTION 3. CRIME INFORMATION
Date of Crime
Date Reported to Police
Name of Suspect
/
/
/
/
Relationship of suspect to victim: _______________________________________________________________________________________________
Name of Police Department Investigating Crime
Police Complaint Number
Investigating Officer’s Name
Location of Crime (address)
City
State
Zip Code
Type of Crime: (please check one)
Assault
DWI/DUI
Homicide/Murder
Child Sexual Abuse
Child Physical Abuse
Stalking
Kidnapping
Arson
Domestic Abuse
Adult Sexual Abuse
Robbery
Burglary
Protection From Abuse (PFA) or PFA ex parte (emergency hearing)
Other
Please specify if other: _______________________________
1
VCAP Claim Form
(1/10)
SECTION 4. LOSS INFORMATION
Check the type of expenses/losses you are seeking for compensation. You must attempt to recover
your losses from any/all other sources(s).
Medical/Dental
Wage/Income Loss
Funeral/Burial
Mental Health Counseling
Crime Scene Cleanup
Mental Health Counseling
Loss of Support for
Moving
Relocation
Temp. Housing
(Secondary Victim)
Victim’s Dependents
Other
Approximate amount of Loss
Please specify if other:
(Must demonstrate a minimum of $25.00 loss.)
$
Name of Secondary Victim’s (last, first, m.i.)
Relationship to Victim
Address
Phone No.
Date of Birth (MM/DD/YY)
/
/
Other Secondary Victim(s)
Relationship to Victim
Address
Phone No.
Date of Birth (MM/DD/YY)
/
/
SECTION 5. MEDICAL INFORMATION
List all Medical/Dental Providers, and/or those who have provided services to the victim and attach any
medical bills you have received.
Name of Provider
Address
Phone
Amount Due
$
Name of Provider
Address
Phone
Amount Due
$
Name of Provider
Address
Phone
Amount Due
$
Name of Provider
Address
Phone
Amount Due
$
SECTION 6. VICTIM’S EMPLOYER
Complete only if filing for income loss
INFORMATION
Name of Employer
Address
City
State
Zip Code
Telephone Number
Fax Number
Was the victim self-employed?
(
)
(
)
Yes
No
Dates absent from work due to crime related injury
Amount of wages lost due to injuries
From:
To:
$
Victim was released back to work on:
By (Name of physician)
Phone Number of Physician
(
)
SECTION 7. SOURCES OF FINANCIAL
Check all that may apply
ASSISTANCE
Did the victim have insurance at the time of the crime?
Does secondary victim have insurance?
Yes
No
Yes
No
Health
Auto
Workers Compensation
Medicaid
Medicare
SSI
Social Security
Disability Benefits
Homeowners/Renters
General
None
Disability
Assistance
Provider Name:
Policy #
2
VCAP Claim Form
(1/10)
ACKNOWLEDGEMENT AND
The Acknowledgement, Reimbursement and Authorization Agreements must be signed before the
REIMBURSEMENT AGREEMENTS
claim verification process will begin.
Certification of Application
Subject to the penalty of fine or imprisonment, the information contained in this application for a Crime Victim Compensation award is
true and correct to the best of my knowledge.
Consent
I agree that any award(s) may be paid directly, at the discretion of the Delaware Victims’ Compensation Assistance Program, to the
person(s) owed payment.
Subrogation Agreement
I agree that I HAVE NOT and WILL NOT sign any release or participate in any settlement or compromise with any person who may be
liable to me for damages as a result of the criminal act for which I am making a claim. In consideration of any award made by the
AGENCY, I agree to subrogate to the AGENCY any right or cause of action to the extent of the award that I may have against any third
party. I authorize the AGENCY to pursue in my name at the expense of the AGENCY recovery from any third party any sums paid to
me from the VICTIM’S COMPENSATION FUND. In any suit that is brought by the AGENCY, I agree to fully cooperate and assist in any
manner including executing and returning papers as required.
Repayment
If later I recover any money through legal action, restitution or otherwise, I agree to immediately repay the award(s) to the AGENCY.
Civil Lawsuit
Will there be a Civil Lawsuit in relation to this crime?
Yes
No
Unknown
If yes, list the name and address of Attorney:______________________________________________________________________
Appeal
I understand if I am dissatisfied with the initial decision of the Victims’ Compensation Assistance Program, I may submit a written
request for a Reconsideration within 15 days after the date the decision is mailed. If the claimant is dissatisfied with the Agency’s final
decision, the claimant, may, within 15 days after the date the decision is mailed, request a hearing before the Appeals Board. If I am not
satisfied with the Appeals Board’s final decision, I understand that I may appeal the decision to the Superior Court of the State of
Delaware within thirty (30) days for the final decision.
Acknowledgement and Reimbursement Agreements
My signature below signifies I understand each of the following statements or points of law:
The decision to approve my claim is that of the Program’s. I may object to all or part of the Program’s decision in writing within 15 days from the date that
the decision is mailed. I must prove the exact amount of my losses before the Program will consider awarding compensation from the Crime Victim’s
Compensation Fund. I may file for reimbursement for additional expenses incurred relating to the crime. My claim may be denied if I do not cooperate
fully with law enforcement agencies, the courts, and the Program or maintain a valid address with the Program. If I were to make a false claim, it would
be a criminal offense punishable as a misdemeanor. If I were to make a false statement in this claim form with the intent to mislead the Program, it would
be a criminal offense punishable as a misdemeanor. I understand that the Delaware Victims’ Compensation Assistance Program is the payor of last
resort. I specifically agree to inform the Program of and repay to the Delaware VCAP any funds that I may receive from any other source that has not
already been considered, as a result of the crime and to the extent of the award. That is, I agree to repay any funds that I receive from the offender, any
other person or source, which compensates me for the injury I suffered. I further agree that if the claim is at any time determined to be in error, false or
fraudulent, I will refund to the Program all sums of money paid by the Program.
X
Your signature must be witnessed
Claimant’s Signature
Date
in order for your claim to be
processed. A witness can be any
adult over the age of 18 who can
X
verify who you are.
Witness Verification of Signature
Date
AUTHORIZATION TO OBTAIN INFORMATION
I hereby authorize in accordance with the privacy regulations under HIPAA (the Health Insurance Portability and Accountability Act, 42 USC§§1320d et
seq.) any hospital, physician, health care provider or other person who attended or examined (Name of Victim) _________________________________
___________________________; any funeral director or other person who rendered related services; any employer of the victim or claimant; any police
or governmental agency, including state or federal taxing authorities; any insurance company; or any organization having relevant knowledge, to furnish
to the Delaware Victims’ Compensation Assistance Program, any and all information in their possession with respect to the incident that is the basis for
this claim. Copies of this authorization may be used in place of the original.
X
Claimant’s Signature
Date
X
Victim’s Signature (if age 18 or over)
Date
3
VCAP Claim Form
(1/10)
Page of 3