Victim Compensation Submission

Form Code CVC

Add CVC Application

a392338224165600
Submitters Email Address*
Email Address is required. This email address will be used to send a confirmation email after Portal Submission is complete.

a392338224947100
APPLICATION SHOULD BE COMPLETED AND SIGNED. IT IS THE RESPONSIBILITY OF THE VICTIM/CLAIMANT TO NOTIFY THIS DIVISION OF ANY CHANGES TO ADDRESS OR TELEPHONE NUMBERS. I UNDERSTAND THAT MISSISSIPPI CODE ANNOTATED § 99-41-31 STRICTLY PROHIBITS THE RELEASE OF ANY RECORDS OBTAINED BY THE CRIME VICTIM'S COMPENSATION DIVISION FOR THE PURPOSE OF PROCESSING A COMPENSATION CLAIM. I UNDERSTAND THAT THIS PROHIBITION APPLIES TO ALL PERSONS WHO ARE NOT DIRECTLY INVOLVED IN DETERMINING ELIGIBILITY, INCLUDING THE CLAIMANT AND/OR CLAIMANT'S COUNSEL.

APPLICATION SHOULD BE COMPLETED AND SIGNED. IT IS THE RESPONSIBILITY OF THE VICTIM/CLAIMANT TO NOTIFY THIS DIVISION OF ANY CHANGES TO ADDRESS OR TELEPHONE NUMBERS. I UNDERSTAND THAT MISSISSIPPI CODE ANNOTATED § 99-41-31 STRICTLY PROHIBITS THE RELEASE OF ANY RECORDS OBTAINED BY THE CRIME VICTIM'S COMPENSATION DIVISION FOR THE PURPOSE OF PROCESSING A COMPENSATION CLAIM. I UNDERSTAND THAT THIS PROHIBITION APPLIES TO ALL PERSONS WHO ARE NOT DIRECTLY INVOLVED IN DETERMINING ELIGIBILITY, INCLUDING THE CLAIMANT AND/OR CLAIMANT'S COUNSEL.

Select the type of compensation you are requesting:

Benefits Requested*

SECTION A - Victim Information - person injured or killed as result of the crime.

First Name*

Middle Name

Last Name*

Marital Status

Mailing Address 1*

Mailing Address 2

City*

State*

Zip*

County

Date Of Birth*

Gender*

Race*

Social Security Number

Home Phone Number

Email Address

Handicap

Name Prefix

Primary Language*

Employment

Complete this section only if the victim was employed at the time of the crime and has loss of wages due to the crime related injuries Note: Victim and claimant may both receive compensation for lost wages. Both awards cannot exceed the maximum of up to $600 per week.
Missed Work From
Missed Work To
Employer Name
Employer Address
Employer Address 2
Employer City
Employer State
Employer Zip
Supervisor Name
Self Employed

If you are self-employed, attach a copy of your latest federal income tax return. (files can be uploaded at the bottom of this application)

Has/had victim veen under the supervision of any department of corrections
(including, but not limited to, incarceration, earned release, house arrest,
probation, parole, conditional medical release or interstate compact) for a
felony conviction within 5 years prior to the victim's injury or death?*

Yes No

Is Victim also the Claimant?*

SECTION B - Claimant Information - If claimant is same as victim, skip to Section C

First Name*

Middle Name

Last Name*

Address 1*

Address 2

City*

State*

Zip*

County

Telephone Number

Email Address

Date Of Birth*

Gender*

Race*

Social Security Number

Name Prefix

Primary Language*

Yes No DUI

Employment

Complete this section only if the claimant missed work and had a loss of wages in order to assist the victim during the victim's recovery from injuries. Note: Victim and claimant may both receive compensation for lost wages. Both awards cannot exceed the maximum of up to $600 per week.
Missed Work From
Missed Work To
Employer Name
Employer Address
Employer Address 2
Employer City
Employer State
Employer Zip
Supervisor Name
Self Employed

If you are self-employed, attach a copy of your latest federal income tax return. (files can be uploaded at the bottom of this application)

SECTION C - Crime Information

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Type of Crime*	Msago Crime Type
Date of Crime*
Describe Injuries To The Victim
Date Crime Reported
Incident Number
Law Enforcement Agency Lookup*	Search Organization
(Start typing the law enforcement agency and the agency will begin to autofill)
Officer Name
Offender Name
Victim Know Offender
Address 1
Address 2
City
State	Us State
Zip
County*	County
Were Charges Filed Against Offender?	Choice
Has an arrest been made?	Choice
Has the case gone to trial?	Choice
If yes, when?
Result?
Court Case or Cause Number
Prosecuting Attorney
Has the court ordered the offender to pay restitution?	Choice

Section E - Loss of Support for Dependent(s)

Complete this information only if the victim financially supported dependent(s) at the time of death.

Multiple dependents can be added by clicking the icon

Dependent

Did victim contribute financial support to any dependent at the time of death?	Yes No
First Name
Middle Name
Last Name
Name Prefix	Name Prefix
Relationship to Victim	Msago Relationship To Victim
Date Of Birth
Address Type	Address Type
Address 1
Address 2
City
State	Us State
Zip
County
Social Security Number
Primary Language	Language

Dependent

Section F - Insurance and Other Collateral Source Information

By law, the Crime Victim Compensation Division is payer of last resort and must verify all sources available for payment of expenses. This section must be completed. Please check each source that applies.

1. Source	Applied For	N/A
Health Insurance
Automobile Insurance
Social Security: SSI
Social Security: Disability
Social Security: Death Benefits
Workers' Compensation
Medicaid
Medicare
Veteran's Administration
Unemployment Compensation
Disability Pay
Life Insurance
Amount of Policy
Beneficiary
Relationship to Victim
Burial Insurance Policy
Amount of Policy
Donations for Funeral Expenses
Amount
Other (specify)

2. Please list name, address and telephone number for each insurance company indicated above.

Insurance Company	Address	Telephone #

3. If a car was involved in the crime, list the name and address of the offender’s automobile insurance company.

Section G - Attorney Information

1. Have you filed or are you considering filing a civil action against the offender or some other third party for damages as a result of the crime? * If yes, please complete the following:

A. Attorney’s Name		B. Telephone #
C. Mailing Address

Section H - Referral Information

Learn About Program*

Documents

a392338415757600
Upload any supporting documentation you may have
files Add files

Section I - Aurhorization, Consent and Subrogation

CONSENT: I acknowledge and agree that all or any part of the compensation award may be paid directly, at the discretion of the Crime Victim Compensation Division, to the person(s) to whom payment is owed.

SUBROGATION: I agree to immediately repay any award(s) to the Crime Victim Compensation Division, if I later recover the money through legal action or otherwise. Furthermore, I agree to notify the Crime Victim Compensation Division in writing prior to filing a civil lawsuit resulting from the criminal action. In consideration of any award made by the Crime Victim Compensation Division, I agree to subrogate to the Crime Victim Compensation Division, or its representatives, any information requested, including tax data and prior police records, needed to perfect my claim for compensation.

AUTHORIZATION: I hereby authorize, in accordance with the privacy regulations under HIPAA (the Health Insurance Portability and Accountability Act, 45 C.F.R. § 164.508) any hospital, physician, health care provider, mental health care provider; any funeral director or other person who rendered related services; any employer of the victim or claimant; any law enforcement or governmental agency, including state or federal taxing authorities; any insurance company; or any other individual, company, agency or organization having relevant knowledge, to furnish to the Crime Victim Compensation Division, any and all information in their possession with respect to the incident that is the basis for this claim.

NOTICE: The individual signing this authorization may request the entity provide them with both a copy of the authorization and a copy of the Protected Health Information (PHI) to be disclosed. The individual signing this authorization has the right to revoke this authorization at any time, provided the revocation is in writing, except to the extent that the entity has already relied upon this Authorization to disclose PHI. A photocopy of this authorization shall be considered as effective and valid as the original. This authorization will expire 3 years from the date the victim/claimant signed below or when this claim is resolved.

CERTIFICATION OF APPLICATION: I hereby certify that I have read and/or understand, and agree to the above statements. I also certify, subject to the penalty of fine and imprisonment, that the information contained in the application for Crime Victim Compensation is true and correct to the best of my knowledge.

*	*
Victim or Claimant Signature (must be 18 years or older to sign)	Date

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Add CVC Application

Select the type of compensation you are requesting:

Lookup List

SECTION A - Victim Information - person injured or killed as result of the crime.

Employment

SECTION B - Claimant Information - If claimant is same as victim, skip to Section C

Employment

SECTION C - Crime Information

Section E - Loss of Support for Dependent(s)

Dependent

Section F - Insurance and Other Collateral Source Information

Section G - Attorney Information

Section H - Referral Information

Lookup List

Documents

files

Section I - Aurhorization, Consent and Subrogation