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1 Please tear off and keep this page with our contact information below. Thank you! DEPARTMENT OF JUSTICE CRIME VICTIMS SERVICES DIVISION APPLICATION FOR CRIME VICTIM COMPENSATION You may qualify for help through this program if you were the victim of a person crime in the state of Oregon. Claims will be verified by the program, through police and other reports. An application must be filled out for each victim. If the victim is deceased, is a minor or an adult unable to fill this out, the applicant (person filing for victim) must be an adult who is responsible for the victim. Please fill out this application as completely and accurately as possible. Type or print clearly. Unsigned applications will be returned unprocessed. If you need help filling out the application please call your local Victim Assistance Office through the District Attorney s Office, or call Crime Victims Compensation at (503) or toll free You have one (1) year from the date of the crime to file an application. Types of expenses we cover include: Medical, dental, hospital, funeral, counseling, loss of wages & support, physical rehabilitation, and transportation. There is NO award for lost or damaged property, or for pain and suffering. Loss of earnings is only payable if the victim is employed and working at the time of the incident. Expenses related to the crime must first be submitted to your insurance for payment, including health, dental, and auto insurance. Any expenses not fully covered by insurance will be considered for payment. You are not required to be a US Citizen to apply for Crime Victim Compensation. Thank you for taking the time to fill out this application. We will let you know by mail or when we receive your application, and then contact you again within 30 to 60 days with our claim decision. What do you need to do? Please let us know if your mailing address or phone number changes. If we request information from you, please be sure to respond within the allowed time. To learn more about the Crime Victims Compensation Program, visit us online at: Favor de cortar y mantenga esta página junto con nuestra información de contacto que aparece abajo. Gracias! DEPARTAMENTO DE JUSTICIA DIVISIÓN DE SERVICIOS PARA VÍCTIMAS DEL CRIMEN SOLICITUD DE COMPENSACION PARA VÍCTIMAS DE CRÍMENES Usted talvez puede calificar para ayuda a través de este programa, si es que usted fue víctima de un crimen personal en él estate de Oregón. Las solicitudes serán verificadas por el programa, por medio de la policía y otros reportes. Cada víctima debe presentar una solicitud. Si la víctima ha fallecido, menor de edad, o un adulto incompetente que no pueda llenar este formulario, el solicitante (persona que solicita en nombre de la víctima) debe ser un adulto quien es responsable por el bienestar de la víctima. Por favor llene esta solicitud de la forma más completa y exacta. Escriba a máquina o en letra de molde legible. Las solicitudes sin firma serán devueltas sin procesar. Si necesita ayuda para llenar la solicitud, llame a la oficina de Asistencia para Víctimas por medio de la oficina del Fiscal de Distrito, o llame al programa de Compensación para víctimas de crímenes al (503) Usted tiene un (1) año desde la fecha del crimen para presentar su solicitud. Los gastos compensables incluyen: Médicos, dentista, hospitales, funerarios, consejeros, pérdida de ingresos y apoyo, rehabilitación física, y transporte. NO hay beneficios para pérdida o daño de propiedad, dolor y sufrimiento. Solamente pagamos pérdida de ingresos si la víctima estaba empleada(o) y trabajando en el momento del incidente. Gastos relacionados a causa del incidente, primero deben presentarse a todas las fuentes de pago disponibles por ejemplo: compañías de seguro, incluyendo seguros de salud, dental, y auto. Los pagos no cubiertos completamente por dichas fuentes, serán considerados para el pago. Para solicitar compensación para víctimas de crímenes no es requisito ser ciudadano de los Estados Unidos. Gracias por tomarse el tiempo para llenar esta solicitud. Le avisaremos por correo postal o electrónico cuando recibamos su solicitud y luego nos comunicaremos con usted de nuevo dentro de un periodo de 30 a 60 días para informarle nuestra decisión sobre el reclamo. Qué necesita hacer? Avísenos si su dirección postal o número de teléfono cambian. Si solicitamos información de su parte, asegúrese de responder dentro del tiempo permitido. Para obtener más información sobre el Programa de Indemnización para Víctimas de Crímenes (Crime Victims Compensación Programa) visítenos en: July 2015 Page ~ 1 ~
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Favor de cortar y mantenga esta página junto con nuestra información de contacto que aparece abajo. Gracias!
Please tear off and keep this page with our contact information below. Thank you! DEPARTMENT OF JUSTICE CRIME VICTIMS SERVICES DIVISION APPLICATION FOR CRIME VICTIM COMPENSATION You may qualify for help
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