Free JD-VS-8SB - Connecticut

survivor benefits application
JD-VS-8SB Rev. 1/09

section one - victim information

name of victim (last, first, middle) last known address age Sex city Birth date State Zip

section two - claimant information

name of claimant (last, first, middle) address age primary language of claimant Would you like to be contacted via email? m yes m no Sex

Home telephone city Birth date

Work telephone State Zip

cell telephone

Email

claimant relationship to victim (you may check more than one relationship if applicable): m child m brother m spouse m sister m parent m grandchild m grandparent m step child m spouse's parent m adopted child m stepparent m administrator

m half brother

m half sister

m designated decision maker m other (ie. DcF case worker)

m party to a civil union

For oFFice use only

claim number

claims examiner

section three - loss of support
are you applying for loss of Support compensation? m yes m no (if yes, please complete below.) For a child, attach or send a copy of the child's birth certificate. For a spouse, attach or send a copy of the marriage certificate. attach additional page if necessary. Dependent's name address (Street, city, State, Zip) Relationship to Victim Birth date (mm/dd/yyyy) Guardian (if minor)

section four - contact person (Person to contact if claimant cannot be reached)

name of contact person (last, first, middle) address Home telephone Work telephone

Relationship to claimant city cell telephone State Zip

section five - attorney representation (Complete only if represented by an attorney for this application)

name of attorney (last, first, middle) address Work telephone Fax

name of firm city Juris number State Zip

section six - crime information (Please fill out this section as completely as possible)
type of crime: m homicide Briefly describe the crime: m dui m hit and run m other

Date of crime Date crime was reported to police

address where crime occurred police department to which crime was reported

police department incident number name(s) of assisting officer(s) Was the crime reported to the police within five days? m yes m no (if not, please explain)

Has an arrest(s) been made? m yes m no m unknown name of offender(s), if known Has the offender(s) been arraigned in court? m yes m no m unknown if yes, court location Docket number

section seven - counseling/medical information

are you applying for compensation of unreimbursed mental health counseling and/or medical expenses? m yes m no list all providers that gave treatment, include mental health counselors, pharmacies (for prescriptions), doctors, hospital and ambulance. attach additional page if necessary. if available, please attach copies of bills. provider's name address telephone

Will there be additional treatment? m yes m no m unknown if yes, provider's name

section eight - insurance & other collateral source information (for claimant)
Have bills been paid or will bills be paid by any of the following sources? yourself m yes m no Veterans' administration private health insurance m yes m no Workers' compensation Medicare m yes m no other (please list) State Medicaid m yes m no name of primary medical insurer address city telephone telephone

m yes m no m yes m no

policy number State Zip

name of secondary medical insurer (if applicable) address city

policy number State Zip

Please note: If you have checked yes to any of the above, medical and mental health counseling bills must be submitted to that source before OVS can consider reimbursement.

section nine - funeral expenses
are you applying for compensation for funeral expenses? m yes m no (if yes, please complete below.) if an estate has been opened, attach or send a copy of the probate court's appointment of the named Fiduciary. attach or send the funeral bill and a copy of the death certificate (original death certificate not required). name of Funeral Home address telephone city State Zip

Have any funeral expenses been paid or will any funeral expenses be paid by any of the following sources? m yes m no Burial insurance m yes m no Veterans' Benefits/insurance m yes m no life insurance m yes m no other m yes m no public assistance m yes m no Please note: If you have checked yes to any of the above, funeral bills must be submitted to that source before OVS can consider reimbursement.

section ten - court related benefits

are you an eligible relative of the victim? m yes m no Eligible relatives, defined by General Statutes section 54-201(4), are spouse, parent, grandparent, stepparent, child, including natural born, step and adopted, grandchild, brother, sister, half brother, half sister, or spouse's parents. are you applying for mileage or travel expenses to attend court proceedings? m yes m no are you applying for wage loss compensation to attend court proceedings? m yes m no (if yes, please complete below.) claimant's Employer Employer's address Date(s) absent from work to attend court proceeding(s). telephone city State Zip

section eleven - restitution and civil action
Did the crime involve motor vehicles? m yes m no (if yes, please provide your automobile insurance policy declaration pages.) Did the court order the defendant to make restitution? m yes m no Have you filed or do you intend to file a civil action? m yes m no (if yes, please complete below.) name of attorney (last, first, middle) address Work telephone Fax name of firm city Juris number State Zip

section twelve - statistical information
How did you find out about the crime victims' compensation program? m community advocate m hospital m office of adult probation m family member m infoline/211 m oVS victim advocate m friend/acquaintance m medical provider m oVS webpage m funeral home m mental health provider m police m poster/brochure

m m m m m

private attorney prosecutor/state's attorney public service announcement telephone book other

Submission of your information regarding race/ethnic background or disabilities is voluntary. m white m black/african american m hispanic m native Hawaiian/pacific islander m american indian/alaskan native m asian m other m unknown

section thirteen - statement of facts and authorization

the undersigned certifies that the information herein is true to his or her best knowledge, information and belief and hereby authorizes any hospital, physician(s), funeral director or other person(s) who attended, examined, or rendered services to ____________________________ and _____________________________ , any employer(s) of the victim/claimant, any police or
victim's name claimant's name

other municipal authority or agency, or public authorities including state and federal revenue services, any insurance company or organization having knowledge thereof, to furnish to oVS or its representative any and all information with respect to the incident leading to the victim's death and the claimant's application made for compensation. a photocopy of this authorization will be considered as effective and valid as the original.

i,____________________________ , authorize oVS to disclose any information in its possession, including confidential
claimant's name

information, to the offices of the court Support Services Division, the State's attorney, the attorney General and to private attorneys retained by oVS or the claimant, and to communicate freely with any of the foregoing when such disclosure and communications are necessary pursuant to General Statutes sections 54-208(e), 54-212 and 54-215.

Further, i understand that oVS may be entitled to receive proceeds that an offender has been ordered to pay the claimant as restitution ordered by the State of connecticut's criminal court system. this is in accordance with General Statutes section 54-215.

i understand that any recovery of my losses from the offender resulting from a civil action that i have brought entitles oVS to reimbursement of two-thirds of any compensation awarded to me and that oVS shall have a lien on the recovery pursuant to General Statutes section 54-212. i understand that i must notify oVS of the filing of any such civil action within thirty days of the filing of the action in court.

Further, i understand that pursuant to General Statutes section 54-212, oVS shall be subrogated to any cause of action i have against the offender. a civil action may be brought on behalf of oVS by the attorney General or by a private attorney hired by oVS. oVS shall furnish me with a copy of the action within thirty days of the filing of the action in court.

claimant signature (Parent or guardian must sign if claimant is a minor or an incompetent adult)
please return completed form to: office of Victim Services 225 Spring Street Wethersfield, ct 06109 contact ovs at: 1-888-286-7347 (toll-free compensation line - ct only) 860-263-2761 www.jud.ct.gov/crimevictim

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