Fillable Printable Form 23776

Form 23776

The Indiana General Assembly created the Indiana Violent Crime Victim Compensation Fund to

provide financial assistance to victims of violent crime, and charged the Indiana Criminal Justice

Institute (ICJI) with managing the fund. Victims and, in some cases, their dependents may be

eligible to receive assistance with certain costs as a direct result of a violent crime. Below are

the eligibility requirements, compensation categories, and payment limits.

Eligibility Requirements

1. The claimant must be a victim, surviving spouse, or a dependent child of a victim of an

eligible violent crime.

2. The crime must have occurred in Indiana.

3. The crime must have been reported to law enforcement within seventy-two (72) hours of the

incident. In addition, the victim and/or claimant must cooperate with law enforcement during

the investigation and prosecution of the crime.

4. The victim must have incurred a minimum of $100 in expenses as a result of the crime.

5. The victim must not have contributed to the crime or to their injury.

6. The application for benefits must be filed with the Indiana Criminal Justice Institute no

later than one hundred eighty (180) days after the date of the crime. Certain exceptions can

be made for exigent circumstances and for victims of child sex crimes.

7. If the claimant is less than eighteen (18) years old, a parent or legal guardian must sign and

date the application.

For special circumstances, claimants should contact ICJI for eligibility information.

Compensation Categories and Payment Limits may include:

1. Medical, dental and mental health counseling-related expenses (not to exceed $15,000).

2. Potential loss of income if the victim was employed at the time of the incident. Loss of

income is only available if the claimant has not reached the statutory $15,000 maximum

payout.

3. Loss of financial support which was provided by victim. Appropriate documentation

required. Loss of financial support is only available if the claimant has not reached the

statutory $15,000 maximum payout.

4. Funeral, burial and cremation expenses not to exceed $5,000.

Note: Please notify ICJI of all changes in name, address or telephone number.

INDIANA CRIMINAL JUSTICE INSTITUTE

VIOLENT CRIME COMPENSATION FUND

101 West Washington Street, Suite 1170E

Indianapolis, Indiana 46204-3414

Telephone: 1-800-353-1484

E-mail: [email protected]

APPLICATION FOR BENEFITS FROM VIOLENT CRIMES COMPENSATION FUND

State Form 23776 (R11 / 2-14)

* This State Agency is requesting disclosure of your Social Security number which is necessary to accomplish the statutory purposes of this this state agency in accordance with

IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

** This information is for statistical purposes only and will have no effect on the eligibility of the claimant.

VICTIM INFORMATION

Name of victim (first, last, middle initial)

Social Security number or tax identification number* Gender

Date of birth (month, day, year)

Race **

Marital status

African American

Multiracial

Indian

Other ______________

Caucasian

Native American

CLAIMANT INFORMATION (If the same as the victim leave blank)

Name of claimant (if different from the victim / first, last, middle initial)

Address of victim or claimant (number and street)

City, state, and ZIP code

Relationship to victim

Gender

Social Security number *

Telephone number

E-mail address

( )

Is this an automobile accident?

Does the victim have physical injuries?

What forms of compensation are you requesting?

CRIME SPECIFIC INFORMATION

Time crime occurred

Name of suspect

Has the suspect been arrested?

Explanation of crime:

If yes, name of auto insurance for:

Suspect: Victim:

Were you employed at the time of the incident?

Telephone number of employer

Yes No

Indicate which of the following covered any of the expenses related to the injuury:

Address of employer (number and street, city, state, and ZIP code)

Name of medical facility for treatment

Name of employer

Police agency reported to

Prosecuting agency

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Is the victim the claimant?

Yes

Questions or concerns: Please contact the Indiana Criminal Justice Institute at 1-800-353-1484 or email at [email protected].

Who is submitting the claim? Victim Claimant Advocate

Hispanic

Pacific Islander

Male

Female

Single

Divorced

Married

Widowed

Separated

Other ________________

Date of crime (month, day, year)

Address of victim (number and street)

City, state, and ZIP code

E-mail address

Telephone number

( )

Male

Female

Medical/Dental/Counseling

Loss of Income

Other ____________________________________

Funeral/Burial

Loss of support

Medicaid

Medicare

Other __________________________________________________________________________

Health Insurance

County Trustee

Worker’s Compensation

Social Security Benefits

Life Insurance Benefits

Charity

Yes No

( )

Date reported to police (month, day, year) Crime type City and county where crime occured

Yes No

Relationship to victim

Are you willing to assist law enforcement with prosecution?

Yes No

If not willing to prosecute. (please explain why)

Police report number

Cause number

Name of officer

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RELEASES AND CERTIFICATION

EMPLOYMENT INFORMATION

Name of individual whose records are to be released

Name of service providers, persons, or organizations authorized to release information

Protected health information or records to be used and/or disclosed

RELEASE OF LIABILITY

I do hereby release the State of Indiana and the Indiana Criminal Justice Institute from any and all liability which might be connected with the

processing and payment of this claim. In the event the fund from which the award is paid, if the claim is allowed, is such that it is necessary to

prorate the payment of the claim, I do hereby release and discharge the State of Indiana and the Indiana Criminal Justice Institute from any and

all liability beyond the amount actually paid to me from the fund.

SUBROGATIONS

The claimant hereby certifies that no release has been or will be given in settlement or for compromise with any third party who may be liable in

damages to the claimant; and the claimant, in consideration of any payment and/or award by the Indiana Criminal Justice Institute in accordance

with IC 5-2-6.1-22, here subrogates the State of Indiana to the extent of any such payment and/or award to any right or cause of action occurring

to the claimant against any third person, and agrees to accept any such payment and/or award pursuant to the provisions of the statute. The

claimant hereby authorizes the State of Indiana to sue in his/her name, but at the cost of the State of Indiana, pledging full cooperation in such

action, to execute and deliver all papers and instruments, and do all things necessary to secure such right to a cause of action.

CONSENT TO PAY PROVIDERS

I do hereby consent and agree that if an award is made, money due and owing to any provider of medical services and due to any other qualified

person or entity, including any attorney's fees allowed to my attorney, may be paid direct to said provider, entity or attorney by the agency and

need not be paid to me.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize the use and/or disclosure of my protected health information described below. I understand this authorization is voluntary and made to

confirm my direction.

I understand that, if the persons or organizations I authorize to receive and/or use the protected health information described below are not health plans,

covered health care providers, or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected

health information and it may no longer be protected by federal health infomation privacy laws.

I hereby authorize any hospital, physician, undertaker or other person who rendered services to or for the below named individual; any employers of the

below named individual; any police or other municipal authority or agency, or public authority; any insurance company or organization, or its

representative, to release any and all information with respect to the incident resulting in below named individuals personal injury or death, and the claim

made herewith for benefits.

A photocopy of this authorization will be considered as effective and valid as the original.

I, the undersigned Claimant, hereby certify under the penalties of perjury that the statements made herein are true to the best of my knowledge and

belief and were made for the purpose of inducing the State of Indiana to award benefits to me for losses incurred as described above through the

Indiana Criminal Justice Institute as prescribed in IC 5-2-6.1-40.

Signature of claimant Date (month, day, year)

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Initial

Social Security number *

ENTITIES AUTHORIZED TO USE OR DISCLOSE:

Name or specifically identify the persons or organizations who you are authorizing to make use of and/or disclose the protected health information

described above:

Indiana Criminal Justice Institute