EFTA01650839.pdf

4 Tell us about the suspect. Suspects name (If you know) _reier-6-1 cza:11. /hi Has the suspect been arrested for this crime? 0 Yes No S. Has the suspect been prosecuted for this cnme? 0 Yes No 0 Not Yet tg) Does the suspect live in the same house as the victim OR is the suspect a member of the victims family? 0 Yes g..No Has the court issued an order of protection in this case? 0 Yes ,8No (If Yes, attach a copy ) Has the DA asked the court to order restitution? 0 Yes 0 No 0 Not Yet 7 Did the court order the suspect to pay restitution? 0 Yes (Amount S 1 0 No g Not Yet NOTE - If you are eligible for compensation, the OVS may be able 10 reimburse for the expenses listed below These items should also be requested as part of court ordered restitution Applicants are encouraged to share this information with prosecutors if there is a criminal case See the Court Ordered Restitution Information page for important information about restitution 5 Tell us about your expenses related to this crime. (Check all that apply) O med.caLamboanot 0 Loss of Support DS. Lost Wages Personal Transportation O Cnrne Scene Cleanup (Death Clam Onlyt 0 DV Sheller g mothcaucounsong 2 Security Device/System 0 VocationaLftehabditation EA Moving/Sterne D Court El Counseling 0 Funeral/Burial 0 Essential Personal Property O Other (Explain) — - 6 List any essential personal property, like cash, eyeglasses, or clothing that needs to be replaced because of this crime ill none skip to 7 ) Describe what was lost/damaged Cosi Describe what was lost/damaged Cost 1 $ 4 $ 2._ $ 5 $ S 6 S HomeowneraRenter Insurance Company Policy or Oa DedoctitA $ Auto'Cither Insurance Company Policy or 101 Deductible S — if there were no injuries and you are only asking for essential personal property benefits, skip to 15. — 7 Tell us about the victim's or the parent's employment and insurance for Lost Wages. If you do not want us to contact your employer, you cannot ask to be reimbursed for Lost Wages. (Skip to 8 ) Was the maim/parent of hospitalized minor victim employed when the came happened? 0 Yes eeNo (If No, skip to 8 ) Did the victimiparent of hospitalized minor victim miss work because of the crime? 0 Yes 0 No Was the victim/parent self-employed? 0 Yes 0 No al Yes, attach comes of last year's federal tax return and all schedules ) Employers Name. Address. and Phone a ( ) Employer Street Cry State Zip Code Phone N Other Employer's Name. Address, and Phone # I ) Employer Stray City State Zs, Code Phone a Name. Address, and Phone N of doctor who certified victim could not go to work: ( )___. Doctor Street City Stale Zia Code Phone • Tell us about any insurance company that will cover the victim's lost time at work (If none, write -Nara- below and slop to 8 ) Policy a ID N or None' Policy or 11) N or'None" 1 Unemployment Insurance 5 Workers' Canpensabwi 2 Doabley Insurance 6 Other insurance 7 Social Security Benefits (ssn SSN 3 PenVon Plan requited) 8 551 Benefits (ssn requited) StN 4 Other insurance expenses. (Il not, skip to 9 ) 8 If the victim died, fill out below if you have any burial a copy of the funeral home contract, other bets for Dunal expenses and a photocopy of the Death Certificate if you give thorn Also, attach Phone fl Name of Funeral Home Address Rev September 2016 '..en 7 of 4 EFTA01650839