Get Victims Compensation Assistance Program Short Form

This guide offers step-by-step instructions on how to effectively complete the Victims Compensation Assistance Program Short Form online. Understanding the components of the form and the necessary information will help ensure your claim is processed smoothly.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by providing your victim information. Fill in your full name, date of birth, Social Security number, address, city, state, zip code, county, and contact phone numbers.
3. If someone other than the victim is submitting the claim, complete the claimant information section. Write 'SAME' if the victim is also the claimant.
4. Enter the crime information, including the date of the crime, the date it was reported to the police or a Protection From Abuse order was filed, and indicate if the crime was a domestic violence incident, involved a motor vehicle, or occurred at work.
5. Describe the location of the crime, the police department involved, the police incident number, and provide details about the individuals who committed the crime as well as a brief description of the crime and injuries.
6. Proceed to the benefits section and complete the applicable fields regarding medical expenses, funeral expenses, loss of earnings, and stolen cash. Provide any available itemized bills and indicate if you have insurance.
7. Sign the Acknowledgment and Reimbursement Agreement on the back of the claim form. This signature confirms your understanding of the terms and conditions associated with your claim.
8. Complete the Authorization to Obtain Information section by providing your signature. This consent allows the Program to retrieve necessary information related to your claim.
9. Once you have completed all sections of the form, review your information for accuracy. Then, save your form, download it for your records, and prepare to submit your claim.

Take the next step in your recovery process by completing your Victims Compensation Assistance Program Short Form online today.