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Page 1 Revised: May 2022 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: [PHONE REDACTED] Fax: [PHONE REDACTED] The Victim Compensation program operates pursuant to C.R.S. §24-4.1-101 et seq. Eligibility Requirements: 1. 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 direct result of a compensable crime. 2. The victim must cooperate with law enforcement officials district attorney, police, and sheriff). 3. The law enforcement agency was notified within 72 hours after the crime occurred. 4. The injury or death of the victim was not the result of the victim’s own wrongdoing or substantial provocation. 5. The victimization occurred on or after July 1, 1982. 6. The application for compensation must be submitted within one year from the date of the crime; six months for residential property damage claim. 7. For further information regarding CVC, please call [PHONE REDACTED] 8. If the victim/applicant is hearing impaired, you may contact the CVC program by emailing [EMAIL REDACTED]. 9. If the victim applicant is blind, please contact the CVC Program by calling [PHONE REDACTED] or going to your local district attorney office. 10. If the victim/applicant does not speak English, please contact the CVC Program by coming to 136 Justice Center Rd., Rm. 203, Canon City, CO or 104 Crestone Ave., Rm. 120, Salida, CO 81201 or, 310 4th St. Fairplay, CO 80440 so you can meet with a CVC staff member and interpreter. 11. All materials received, made, or kept by the CVC Program or district attorney concerning an application for victim’s compensation made under C.R.S. §24-4.1-100.1 are confidential. Victims have a right to be notified by the district attorney’s office if a subpoena has been issued by the court for the CVC claim file, or materials in the CVC claim file, for which the victim applied. NOTE: The Compensation Board MAY waive some of these requirements for good cause or in the interest of justice. ---PAGE BREAK--- Page 2 Revised: May 2022 General Information: 1. There does not have to be an arrest made for a victim to be eligible for compensation. However, a report to Law Enforcement must have been made. This is required. 2. 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. Victims of domestic violence are not eligible for loss of household support if they reunite with their perpetrator. 3. 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. 4. By law, you must apply for all other available sources of financial assistance or reimbursement, including private insurance, Medicaid, and Medicare. 5. Please attach all bills and receipts. You may apply even if you have not received any bills as of this date. 6. Your claim will be investigated and presented to the Victim Compensation Board. This process may take up to forty-five days. 7. Total recovery may not exceed the statutory limit of $30,000. Compensation for some categories is limited by Board policy. 8. 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. 9. Contact the CVC Program at [PHONE REDACTED] if crime related bills have been turned over to a collection agency. 10. Submission of an application does not guarantee, or secure, the receipt of an award. PLEASE KEEP THE FIRST TWO INFORMATION PAGES OF THE APPLICATION. ---PAGE BREAK--- Page 3 Revised: May 2022 Please complete every question, write N/A if the question is not applicable. SECTION 1 - VICTIM INFORMATION (PLEASE TYPE OR PRINT) Victim’s Name (First, Middle, Last) Email Address Mailing Address City/State/Zip Home Phone Work phone Cell Phone Date of Birth Age when crime occurred State of Residency Sex: □ Male □ Female The following information is used for statistical purposes only. It is needed to comply with federal regulations. Handicapped: Race: White Non-Latino or Caucasian Yes Physical Black or African American No Mental Hispanic or Latino American Indian or Alaska Native Asian Native Hawaiian or Other Asian Pacific □ Multiple Races Some Other Race Who Referred You to the Compensation Program? District Attorney Victim Advocate Therapist Law Enforcement Victim Advocate Hospital Police Officer Other: Human Services ---PAGE BREAK--- Page 4 Revised: May 2022 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). Claimant’s Name AND Birthdate Email Address Mailing Address City/State/Zip Home Telephone Work Telephone Relationship to Victim SECTION 3 - CRIME INFORMATION (All applicants must complete this section) Type of Crime: Domestic Violence Drunk Driver/Vehicular Assault/Homicide Assault Child Physical Abuse Burglary/Criminal Mischief Child Sexual Assault by Family Member Sexual Assault – Adult Child Sexual Assault - Non-Family Member Murder/Homicide Other Date of Crime: Police Dept./Agency Crime Was Reported To: Crime Report Law Enforcement Officer Handling Case: Who Committed the Crime if Known: Suspect’s Relationship to Victim: Did the Crime Occur at Work? Yes No County Where Crime Occurred: INCLUDE COPIES OF ITEMIZED BILLS WITH THIS APPLICATION. PLEASE FORWARD ADDITIONAL CRIME RELATED BILLS AS YOU RECEIVE THEM. ---PAGE BREAK--- Page 5 Revised: May 2022 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 MEDICAL SERVICES: Submit copies of itemized medical bills, if available. Hospital: yes no Physician: yes no Chiropractic: yes no Dental: yes no Physical Therapy: yes no Home Nursing Care: yes no Ambulance: yes no Mileage to/from medical appointments if more than 50 miles: yes no PERSONAL MEDICAL ITEMS: Submit copies of itemized bills, if available. (Limited to medically necessary devices damaged or destroyed during the crime.) Eyeglasses/Contact Lenses: yes no Dentures: yes no Hearing Aids: yes no Prosthetic Device: yes no Prescriptions: yes no Other: yesno Please List: COUNSELING: Submit copies of itemized bills, if available. If already in therapy, please provide the following: Therapist’s Name: Telephone No. Mailing Address: Email Address: LOSS OF HOUSEHOLD SUPPORT: See pages 12-13 – Due to a compensable crime, the offender vacated any home that was shared AND was financially contributing to the household. You MUST provide documentation of the offender’s income). ---PAGE BREAK--- Page 6 Revised: May 2022 LOSS OF WAGES: Please submit the attachment titled “Loss of Wages”, pages 10-11. Did you use any of the following? Paid Sick Leave Paid Vacation Leave_______ Paid Personal Leave______ ______FUNERAL EXPENSES: Submit copies of itemized bills when available. ______RESIDENTIAL PROPERTY: Submit copies of itemized bills or quotes when available, or quote. (Limited to exterior residential doors locks and windows damaged or destroyed during the crime. This must be items necessary to ensure safety.) Doors: Yes No Locks: Yes No Windows: Yes No Residential insurance deductible amount: $ ________RELOCATION ASSISTANCE: You must provide address where you are relocating, name and phone number of landlords, family member, friend, etc. of where you are relocating to and include all itemized receipts. Due to fluctuating costs, relocation may be done on a reimbursement basis. LOSS OF SUPPORT TO DEPENDENTS: Financial assistance for children and/or dependents whose family member was killed as a result of a compensable crime AND was a contributing wage earner for the family. You MUST provide verification of the income of the deceased individual whose support you have lost. Please provide proof of the deceased’s income in the form of Paystubs, Taxes, 1099 or Proof of Joint Account. ---PAGE BREAK--- Page 7 Revised: May 2022 EMERGENCY/URGENT AWARDS: The compensation fund MAY assist victims if they are determined to require emergency assistance as a direct result of the crime. (Emergency awards are defined as an urgent need that requires immediate attention prior to the next scheduled Board meeting.) Contact the Victim Compensation Administrator at [PHONE REDACTED], M-F 8-5, to see if emergency awards are available and for additional information on this benefit. Benefits are limited to $2,000.00 and must be used within 30 days of a reported criminal act. Awards will be reviewed on a case-by-case basis). For this section, see Brochure. SECTION 5 - INSURANCE INFORMATION All applicants seeking compensation must complete the following information on insurance and other sources available to pay medical bills and counseling. SOURCE: YES NO UNK Name of Insurance Company/Policy No./Phone No. Private Insurance Medicaid Group Insurance Medicare Worker’s Comp. Disability Ins. Automobile Ins. Homeowner’s/ Renter’s Ins. Military Coverage Other _______TRAVEL: Explain in detail what you are requesting travel for. Provide copies of receipts for reimbursement. (You may be eligible for travel assistance to attend counseling or medical appointments related to injuries received in the crime. Verification of your attendance at an appointment is required). ---PAGE BREAK--- Page 8 Revised: May 2022 ________LODGING: Explain in detail what you are requesting lodging for. Please provide copies of receipts for lodging costs for Court Appearances. (Lodging, travel, and meals provided for attending funeral of victim who is deceased as the result of a crime or immediate family members attending a sentencing hearing will be awarded on a case-by-case basis) SECTION 6 – CIVIL LAWSUIT Are you planning to sue the person(s) or business/agency responsible for this injury? yes no If yes, provide the following: Your Civil Attorney’s Name: Mailing Address: City/State/Zip: Telephone No: 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. ---PAGE BREAK--- Page 9 Revised: May 2022 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. Printed Name of Victim or Claimant Signature of Victim or Claimant Date FOR FURTHER INFORMATION AND ASSISTANCE CONTACT THE VICTIM COMPENSATION ADMINISTRATOR AT 136 JUSTICE CENTER RD., ROOM 203, CANON CITY, CO 81212. PHONE: [PHONE REDACTED]. ---PAGE BREAK--- Page 10 Revised: May 2022 VICTIM COMPENSATION PROGRAM Eleventh Judicial District 136 Justice Center Rd., Room 203 Canon City, CO 81212 (719) 269-0170 Please print LOSS OF WAGES VICTIM NAME: The program will only compensate the victim for wages lost due to physical or emotional injuries directly caused by the crime. Lost wages will not be paid for time lost due to court appearances, appointments with criminal justice personnel or appointments with service providers. If you are requesting loss of wages, take this form to your employer and have it completed and signed by your supervisor/employer each month. If you are self-employed, you must submit copies of your tax returns or 1099. If claiming lost wages, you must supply the following documentation: 1) This form must be completed and returned before your request for lost wages can be processed. Please return the original form with your application or send to the address listed above. 2) A letter from your treating physician or therapist indicating your inability to work due to physical or emotional injuries sustained as a direct result of the crime and indicating length of time of inability to work. 3) If requesting lost wages for more than one month you must take this form to your employer each month for verification EMPLOYEE'S NAME: JOB TITLE: WAS THIS PERSON EMPLOYED ON THE DATE OF INJURY? YES NO HAS THIS PERSON RETURNED TO WORK? YES NO IF YES, DATE RETURNED? / / WAS THIS PERSON INJURED WHILE AT WORK? YES NO IF YES, WAS WORKERS COMP PAID? YES NO IF YES, THROUGH WHAT PERIOD FROM: TO: WAS SICK LEAVE / ANNUAL LEAVE OR DISABILITY PAID? YES NO IF YES, THROUGH WHAT PERIOD FROM: TO: HOURS WORKED PER DAY TOTAL NUMBER OF DAYS MISSED RATE OF PAY HOURLY WEEKLY COMMISSION $ DAILY OTHER TOTAL AMOUNT OF GROSS LOSS OF WAGES: $ ---PAGE BREAK--- Page 11 Revised: May 2022 Employer's (firm) name: Address: City, State, Zip Employer (supervisor/representative) name: Job title: Employer Email: Phone number: REQUIRED SIGNATURES: Employer (supervisor/representative) Employee (victim) signature: *NOTE: This information may be verified by the Victim’s Compensation Administrator ---PAGE BREAK--- Page 12 Revised: May 2022 11th JUDICIAL DISTRICT CRIME VICTIM COMPENSATION PROGRAM LOSS OF HOUSEHOLD SUPPORT REQUEST Victim Name: Defendant Name: Are there any dependents? □Yes No If yes, *See page 14 Were you and the defendant living in the same residence at the time of the crime? Y / N At the time of the crime the defendant was providing: Total Support Partial Support support Income: Defendant: $ per Your: $ per (YOU MUST PROVIDE DOCUMENTATION OF DEFENDANTS SUPPORT) Are there any other sources of income? □Yes □ No If “yes,” please list: To your knowledge, is the defendant refusing to continue providing financial support? □Yes No Please itemize the following expenses and provide documentation: Defendant pays: You pay: Total: Housing (rent/mortgage) Gas Electric Water/Sewer Phone Food Other-List: Total: ---PAGE BREAK--- Page 13 Revised: May 2022 Will the defendant benefit from any lost support payments made by the CVC Program? □Yes No If “yes,” please explain: I certify that I have read and/or understand and agree to all the statements in the Application for Crime Victim Compensation, Section H - Declarations; furthermore, I am aware that all of the information provided in this Request for Lost Support is subject to those Declarations. I certify that the information contained in this application for lost support is true and correct to the best of my knowledge, and I understand that any untruthful statements will disallow my eligibility for all benefits from the Crime Victim Compensation Fund Signature: Date: ---PAGE BREAK--- Page 14 Revised: May 2022 CHILD/DEPENDANT INFORMATION: List the full names and birthdates for the child(ren)/dependents for which the offender provided financial support. For each child/dependent, list the crime related services you are requesting. 1. Name DOB Services Requested: Circle all that apply: Medical Ambulance Counseling Medical Equipment Dental Other: Explain: 2. Name DOB Services Requested: Circle all that apply: Medical Ambulance Counseling Medical Equipment Dental Other: Explain: 3. Name DOB Services Requested: Circle all that apply: Medical Ambulance Counseling Medical Equipment Dental Other: Explain: 4. Name DOB Services Requested: Circle all that apply: Medical Ambulance Counseling Medical Equipment Dental Other: Explain: