Application For Crime Victim Compensation

Ohio Victims of Crime Compensation ProgramApplication for CompensationIf you or your family members are innocent victims of a violent crime, The Ohio Victims of Crime Compensation Program helps victims with certain out-of-pocket expenses caused when people are physically injured, emotionally harmed by Ohio222s taxpayers.For more information, call: 614-466-5610Toll-free numbers:800-582-2877For general information:877-584-2846 (877-5VICTIM)www.OhioAttorneyGeneral.gov American LegalNet, Inc. www.FormsWorkFlow.com ELIGIBILITY CHECKLIST If you answer 223yes224 to all these questions, you may be eligible for help from this program. WHO MAY BE ELIGIBLE? for that victim/family member WHO IS NOT ELIGIBLE? the injury or during the pendency of the claim injury or during the pendency of the claim to the crime that caused the injury or during the pendency of the claim WHAT ARE SOME COSTS THAT MAY BE PAID? certain cases, aiding in the care or recovery of the victim ARE THERE LIMITS ON COMPENSATION? American LegalNet, Inc. www.FormsWorkFlow.com Ohio Victims of Crime Compensation ProgramApplication for Crime Victim Compensation Please type or print using blue or black ink SECTION 1: VICTIM INFORMATIONPerson injured or killed as a result of the crime. If more than one victim is affected, a separate application is required for each. þ þ þ þ þ Victim is/was: a. male female þ b. single married separated divorced widowedIf yes, list each state and indicate when the victim lived there.SECTION 2: CLAIMANT INFORMATION (if different than the victim) Claimant cannot be a minor or a service provider.A 223claimant224 is a non-victim who paid or is obligated to pay out-of-pocket expenses as a result of this victimization. þ þ þ þ þ Claimant is: a. male female þ b. single married separated divorced widowed If yes, list each state and indicate when claimant lived there.SECTION 3: CRIME INFORMATION þ þ Use additional sheet if necessary. þ Other American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4: COMPENSATION REQUESTED þ Check all that apply.SECTION 5: VICTIM222S FIRST MEDICAL TREATMENT þ þ þ þ þ SECTION 6: INSURANCE AND BENEFIT INFORMATION þ If yes, check all boxes that apply and give details in the space provided. þ þ þ þ þ þ þ þ þ þ Policy no. Group no. SECTION 7: EMPLOYMENT INFORMATION þ þ þ þ þ þ þ þ SECTION 8: FUNERAL EXPENSES Funeral home name and complete address Clothing damaged by medical treatment Protection order fees Funeral and burial Items held as evidence by law enforcementCounseling expenses for victim Crime scene cleanup þ what the victim would typically do such as Counseling expenses for immediate family members Travel/lost wages to attend criminal justice proceedings when a victim is deceasedFuture loss of support/care for dependents of a deceased victim Mileage (Please send front and back copy of card) American LegalNet, Inc. www.FormsWorkFlow.com SECTION 9: ALL MINOR DEPENDENTS OF DECEASED VICTIMS Use additional sheets if needed. SECTION 10: ATTORNEY AND/OR VICTIM ASSISTANCE PROGRAMHas a private attorney represented you in: Filing this claim? SECTION 11: VICTIM STATISTICAL INFORMATION For statistical purposes only. This is strictly voluntary. SECTION 12: SUBROGATION, AUTHORIZATION, AND SIGNATUREYOU MUST BE 18 YEARS OF AGE OR OLDER TO SIGN THE APPLICATION. þ þ þ þ I understand that if I get money from any other source to cover the same expenses paid through the Crime Victims Compensation Program, I must reimburse the state of Ohio that Compensation Program. I understand that the information I have provided is being relied upon as truthful and accurate. By signing below, I swear or solemnly af037rm under penalty of law that all information provided by me or on my behalf is true and accurate to the best of my knowledge and belief.Signature of person seeking compensation (or signing as the legal guardian of a minor) þ Date of signatureThis release must be signed and dated for the application to be processed. x þ þ To submit an application, an attorney is not required. If an attorney does help, he/she must sign the application. An attorney cannot charge an applicant for his/her representation and must submit fees to the Ohio Victims of Crime Program. þ ATTORNEY ASSISTANCEVICTIM ASSISTANCE PROGRAMIn some cases there may be a local advocate available to help you. American LegalNet, Inc. www.FormsWorkFlow.com AUTHORIZATION FOR USE OR DISCLOSURE OF PSYCHOTHERAPY NOTESPATIENT222S NAME:SOCIAL SECURITY NUMBER:DATE OF BIRTH:ADDRESS:VICTIM/CLAIMANT222S NAME: þ PSYCHOTHERAPY NOTES.mental health care providers, insurance companies, billing departments, health care clearinghouses, health plans, and pharmaceutical used in any way necessary related to my/the patient222s claim for an award of reparations from the Ohio Victims of Crime Compensation Program.I understand that medical records may contain information regarding care of psychiatric/psychological conditions, drug or alcohol date of my signature. VICTIM222S/CLAIMANT222S SIGNATURE þ DATE CLAIMANT222S RELATIONSHIP TO VICTIM Signature required above. Do not write in this space. For internal use only.Claim number:x American LegalNet, Inc. www.FormsWorkFlow.com AUTHORIZATION FOR USE OR DISCLOSURE OF INFORMATION PATIENT222S NAME:SOCIAL SECURITY NUMBER:ADDRESS:VICTIM/CLAIMANT222S NAME: þ THE PATIENT222S ENTIRE RECORD, excluding psychotherapy notes.This information is to be disclosed by any covered entity, including any physician, medical facility, health care provider, mental health care provider, insurance company, billing department, health care clearinghouse, health plan or pharmaceutical entity, employer necessary related to my claim for an award of reparations from the Ohio Victims of Crime Compensation Program.I understand that medical records may contain information regarding care of psychiatric/psychological conditions, drug or alcohol abuse, date of my signature. VICTIM222S/CLAIMANT222S SIGNATURE þ DATE CLAIMANT222S RELATIONSHIP TO VICTIMSignature required above. Do not write in this space. For internal use only.Claim number:x American LegalNet, Inc. www.FormsWorkFlow.com