OVS Application Form

New York State Office of Victim Services
Claim Application and Instructions

1 Columbia Circle, Suite 200, Albany, NY 12203-6383 | (518) 457-8727

55 Hanson Place, Room 1000, Brooklyn, NY 11217-1523 | (718) 923-4325 | 65 Court Street, Room 308, Buffalo, NY 14202-3406 | (716) 847-7992

How to Apply for Compensation

Who can apply for compensation? Innocent victims of crime, certain relatives, dependents and the guardian can apply to OVS for compensation of out-of-pocket expenses not covered by insurance or other resources.

What kinds of expenses can I get compensated for? Medical, pharmacy and counseling expenses; loss of essential personal property; burial or funeral expenses; lost wages or lost support; transportation; occupational/vocational rehabilitation; security and shelter; crime scene clean-up; and Good Samaritan property losses.

Application for Compensation

Please print. Answer all questions. It is a crime to file a false claim!

1 Tell us about the victim.

Race/Ethnicity:

White Black Asian/Pacific Islander Hispanic American Indian/Alaskan Native Other Unknown

Marital Status: Single Married Divorced Separated Widowed Lives with partner

Gender: Male Female Was the victim disabled at the time of the crime? Yes No Unknown

How did you first hear about the Victim Services Program? Police Hospital District Attorney Victim Assistance Program Radio/TV Brochure/Poster Internet Other

2 If you are not the victim, and are signing this claim, tell us about you.

What is your relationship to the victim? (Check only one.) Parent Spouse Child Guardian Attorney Other

3 Tell us about the crime.

The victim died because of: Motor Vehicle (DWI) Motor Vehicle (Other) Terrorism Arson Human Trafficking Other Homicide

The victim was injured because of: Assault Stalking Sexual Assault Kidnapping Child Physical Abuse Terrorism Child Sexual Abuse Arson Motor Vehicle (DWI) Robbery Motor Vehicle (not DWI) Human Trafficking Other

The victim lost essential personal property because of: Burglary/Robbery Arson Motor Vehicle (DWI) Motor Vehicle (not DWI) Human Trafficking Other

Where did the crime happen? Work Owned residence Apt. Bldg. Public Street Subway/Bus Parking Lot Restaurant/Bar School/School grounds Shopping Mall Other

Crime Report # Police or criminal justice agency reported to

4 Tell us about the suspect.

Arrested? Yes No

Prosecuted? Yes No Pending

Live in same house or family member? Yes No

Order of protection? Yes No

Restitution? Yes No Pending

5 Tell us about your expenses related to this crime.

Medical Medical transportation Funeral/Burial Court Transportation Crime Scene Cleanup Loss of Support Lost Wages DV Shelter or Moving Security Device/System Vocational/Rehabilitation Counseling Essential Personal Property Other

6 List any essential personal property.

Homeowner/Renter Insurance Company Policy or ID # Deductible $

Auto/Other Insurance Company Policy or ID # Deductible $

If there were no injuries and you are only asking for essential personal property benefits, skip to 15.

7 If the victim was injured or died because of this crime, fill out below.

Did the victim receive any medical treatment? Yes No

Health professionals who treated the victim:

8 Tell us about the victim’s dependents or others who depended on the victim for support.

9 Did anyone besides the victim receive counseling because of this crime?

10 List any insurance covering the victim or the victim’s dependents.

11 Tell us about the victim’s or the parent’s employment and insurance for Lost Wages.

Was employed when the crime happened? Yes No

Missed work because of the crime? Yes No

Self-employed? Yes No

Insurance covering lost time at work:

Unemployment Insurance Disability Insurance Pension Plan Other insurance

12 If the victim died, fill out below if you have any burial expenses.

13 If the victim died, tell us about any life insurance and death benefits.

Do any of these policies cover burial expenses? Yes No

Has anyone applied for the Social Security Death Benefit? Yes No

14 Tell us about your financial situation.

15 Is a private lawyer helping with this claim or representing you in a civil suit?

Yes No

16 Claimant’s Authorization

HIPAA Authorization for Release of Health Information

Patient Name, Date of Birth, Social Security Number, and Patient Address

9(a) Specific information to be released:

Medical Record from date to date Entire Medical Record Other

Include: Alcohol/Drug Treatment Mental Health Information HIV-Related Information

9(b) Authorization to Discuss Health Information:

Additional notes / attachments