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VICTIM COMPENSATION APPLICATION
ELEVENTH JUDICIAL DISTRICT
STATE OF COLORADO
RETURN COMPLETED APPLICATION TO:
Victim Compensation, 136 Justice Center Rd., Rm. 203, Canon City, CO
81212. Phone: 719-269-0170, Fax: 719-269-0180
Canon City, CO 81212
The Victim Compensation program operates pursuant to C.R.S. §24-4.1-101 et
seq.
Eligibility Requirements:
The crime must be one in which the victim sustains mental or bodily
injury, dies, or suffers property damage to locks, windows or doors to
residential property as a result of a compensable crime.
The victim must cooperate with law enforcement officials (e.g. district
attorney, police, sheriff).
The law enforcement agency was notified within 72 hours after the crime
occurred.
The injury or death of the victim was not the result of the victim’s own
wrongdoing or substantial provocation.
The victimization occurred on or after July 1, 1982.
The application for compensation must be submitted within one year from
the date of the crime; six months for residential property damage claims.
General Information:
- There does not have to be an arrest made for a victim to be eligible for
compensation.
- Compensation may be made for medical expenses, mental health counseling,
dentures, eyeglasses, hearing aids, or other prosthetic or medical devices,
loss of earnings, outpatient care, homemaker or home health services, funeral
expenses, and loss of support to dependents.
- Compensation for property damage may be awarded for the cost of
replacement or repair to doors, locks or windows that are damaged during the
commission of a crime.
- By law, you must apply for all other available sources of financial
assistance or reimbursement, including private insurance, Medicaid and
Medicare.
- Please attach all bills and receipts. You may apply even if you have not
received any bills as of this date.
- Your claim will be investigated and presented to the Victim Compensation
Board. This process may take up to 60 days.
- Total recovery may not exceed the statutory limit of $20,000. Compensation
for some categories is limited by Board policy.
- Should your claim be denied, you have a right to request reconsideration
of the Board’s decision and have the right to submit new or additional
information related to the reason(s) for the Board’s denial or reduction of
your claim. You may arrange for reconsideration by contacting the Victim
Compensation program within 30 days from the date in which you receive notice
of the denial or reduction of your claim. If you request reconsideration of
the Board’s decision, further information concerning the reconsideration
process will be mailed to you. In the event the denial is upheld by the Board,
you have a right to have the Board’s decision reviewed in accordance with the
Colorado Rules of Civil Procedure within 30 days.
Please complete every question, write N/A if the question is not applicable.
SECTION 1 - VICTIM INFORMATION (PLEASE TYPE OR PRINT)
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Victim’s Name (First, Middle, Last) |
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Social Security Number |
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Mailing Address |
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City/State/Zip |
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Home Telephone |
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Work Telephone |
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Date of Birth |
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Age when crime occurred |
Sex: * Male
* Female |
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State of Residency |
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The following information is used
for statistical purposes only. It is needed to comply with federal
regulations. |
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Handicapped: |
Race: |
Who Referred You to the
Compensation Program? |
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* Yes *
Physical |
* White |
* Victim Advocate |
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* No *
Mental |
* African American |
* Police Officer |
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* Hispanic/Spanish |
* District Attorney’s Office |
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* Native American |
* Social Services |
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* Asian Pacific |
* Hospital |
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* Unknown |
* Therapist |
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* Other: __________ |
* Other: _______________ |
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SECTION 2 - CLAIMANT INFORMATION (Complete only
if person submitting application is not the victim, i.e.: victim’s parent or
guardian, or relative of victim).
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Claimant’s Name |
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Social Security Number |
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Mailing Address |
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City/State/Zip |
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Home Telephone |
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Work Telephone |
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Relationship to Victim |
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SECTION 3 - CRIME INFORMATION (All applicants must
complete this section)
| Type of Crime: |
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* Domestic Violence |
* Drunk Driver/Vehicular
Assault/Homicide |
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* Assault |
* Child Physical Abuse |
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* Burglary/Criminal Mischief |
* Child Sexual Assault by Family
Member |
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* Sexual Assault – Adult |
* Child Sexual Assault - Non
Family Member |
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* Murder/Homicide |
* Other
_________________________________ |
| Date of Crime: |
Police Dept./Agency Crime Was
Reported To: |
| Crime Report Number: |
Law Enforcement Officer Handling
Case: |
| Who Committed the
Crime? |
Suspect’s Relationship to Victim: |
| Did the Crime Occur at
Work? * Yes *
No |
County Where Crime Occurred: |
SECTION 4 – BENEFITS Please check each type of claim
for which you are requesting funds, and provide the information requested within
the block or mark the type of claim as not applicable (N/A).
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MEDICAL SERVICES: Submit
copies of itemized medical bills, if available. |
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Hospital:
* yes * no |
Physician:
* yes * no |
Chiropractic:
* yes * no |
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Dental:
* yes * no |
Physical Therapy:
* yes * no |
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Home Nursing Care:
* yes * no |
Other: |
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PERSONAL MEDICAL ITEMS:
Submit copies of itemized bills, if available. |
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(Limited to medically necessary
devices damaged or destroyed during the crime.) |
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Eyeglasses/Contact Lenses:
* yes * no |
Dentures:
* yes * no |
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Hearing Aid:
* yes * no |
Prosthetic Device:
* yes * no |
Other: |
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COUNSELING: Submit copies of itemized bills, if available.
If already in therapy, please provide the following:
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Therapist’s Name: |
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Telephone No. |
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Mailing Address: |
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SECTION 4 - BENEFITS (continued):
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LOST
WAGES: Was the victim able to use any of the following types of leave
due to physical or emotional injury caused by the crime? (You MUST
provide verification of lost wages with a pay stub and a letter from you
employer indicating the number of days of work you missed) |
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Sick Leave:
* yes * no |
Vacation Leave:
* yes * no |
Personal Leave:
* yes * no |
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FUNERAL EXPENSES: Submit copies of itemized bills, if
available.
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RESIDENTIAL PROPERTY: Submit copies of itemized
bills, if available.
(Reimbursement for exterior residential doors, locks
and windows damaged or destroyed during the crime.)
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Doors:
* yes * no |
Locks:
* yes * no |
Windows:
* yes * no |
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Residential
insurance deductible amount: $ |
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LOST
SUPPORT TO DEPENDENTS (You MUST provide verification of the
income of the individual whose support you have lost) |
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EMERGENCY AWARDS: The compensation fund MAY assist victims if
they are determined to require emergency assistance as a direct result of
the crime. Contact your the Victim Compensation Administrator at
719-269-0170 to see if emergency awards are available and for additional
information on this benefit. |
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SECTION 5 - INSURANCE INFORMATION
| All applicants seeking compensation for medical
bills must complete the following information on insurance and other sources
available to pay medical bills. |
| SOURCE: |
YES |
NO |
UNK |
Name of Insurance
Company/Policy No./Phone No. |
| Private Insurance |
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| Medicaid |
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| Group Insurance |
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| Medicare |
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| Worker’s Comp. |
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| Disability Ins. |
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| Automobile Ins. |
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| Homeowner’s/ Renter’s Ins. |
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| Military Coverage |
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| Other |
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SECTION 6 – CIVIL LAWSUIT
| Are you planning to sue the
person(s) or business/agency responsible for this injury?
* yes *
no |
| If yes, please provide the
following: |
| Your Civil
Attorney’s Name: |
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| Mailing Address |
City/State/Zip |
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| Telephone No. |
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| NOTE: The Crime Victim
Compensation Board must be notified of any civil action and be provided with
written evidence of the amount and terms of settlement. |
SECTION 7 - RELEASE OF INFORMATION AND VICTIM’S RIGHTS AND RESPONSIBILITIES
| Certification
of Application: The information contained in this application for a
Crime Victim Compensation award is true and correct to the best of my
knowledge. I understand that the filing of false information
may result in a denial of my claim and is punishable by law. |
| Cooperation:
I understand that my failure to cooperate with law enforcement (police,
sheriff, prosecutor, etc.) may result in the denial of my claim. |
| Alternative
Application Process: If you feel the compensation board in your judicial
district is unable to fairly review your claim due to a personal or
professional relationship with two or more board members, it will be sent to
another district for review. If your claim is approved, bills will be paid
from this office. I understand that this may delay the processing of my
claim. |
| Repayment of
Crime Victim Compensation Award: I understand that the Crime Victim
Compensation Program will be repaid if payments are received from the
offender (restitution or civil action), insurance, or any other government
or private agency as compensation for this injury or death after receipt of
payment from the Victim Compensation Fund. |
| Subrogation
Agreement: I understand that the acceptance of a Victim Compensation
Award by an applicant shall subrogate the state to the extent of such award
to any cause or right of action accruing to the applicant. |
| Release of
Information Authorization: I hereby authorize the release of all
information from my employer, physician, hospital, Department of Human
Services, medical and/or mental health service provider(s) and/or creditor(s)
for the purposes of verifying the claims I have submitted, or to establish
the validity of a restitution claim. I further understand that any
information provided may be subject to disclosure under the law. |
| Release of
Funds: I hereby authorize release of funds awarded to me under the
Colorado Crime Victim Compensation Act to be paid directly to the services
provider(s) applicable to my claim. I understand that any
award is subject to the availability of funds and the discretion of the
Board. |
| Right to
Reconsideration: As an applicant, you are advised that if your Crime
Victim Compensation claim is denied you have the right to request a
reconsideration hearing before the Crime Victim Compensation Board. You will
be entitled to present evidence and witnesses. At said hearing, the burden
of proof is upon you as the applicant to show that the claim is reasonable
and compensable under the terms of the Colorado Crime Victim Compensation
Act. In the event the denial is upheld by the Board at the reconsideration
hearing, the applicant has the ability to have the board’s decision reviewed
in accordance with the Colorado Rules of Civil Procedure within 30 days. |
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| Printed Name |
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Signature of Victim or Claimant |
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| Date |
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FOR FURTHER INFORMATION AND ASSISTANCE CONTACT THE VICTIM COMPENSATION
ADMINISTRATOR AT 136 JUSTICE CENTER RD., ROOM 203, CANON CITY, CO 81212. PHONE:
719-269-0170.
last updated:
03/06/07
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