After an application has been filed, the law may provide for payment of an emergency award of up to $2000 to qualified claimants. Claimants may qualify if they will suffer an undue hardship without immediate economic relief because of the crime and if a final award is likely.
THIS DOCUMENT IS A PUBLIC RECORD. EXCEPT FOR INFORMATION THAT IS PROTECTED BY STATE OR FEDERAL LAW, INFORMATION YOU PROVIDE ON THIS APPLICATION IS SUBJECT TO PUBLIC DISCLOSURE UPON REQUEST.
Crime Victim Section
150 E. Gay St. 25th Floor
Columbus, OH 43215
Section 1: Victim Information
Person injured as a result of the crime. If more than one victim, a separate application is required for each victim.
The following information is for federal statistical reporting only. All information is voluntary and will not affect the claim for compensation.
Section 2: Claimant Information
Claimant: The victim, any person filing on behalf of the victim, or any other person seeking compensation. If there is more than one claimant, each claimant must sign a release. The claimant cannot be a minor.
Section 3: Crime Information
Section 4: Compensation Requested
Check all that apply.
Section 5: Victim's First Medical Treatment
Name, address, and dates of service for victim’s first medical treatment (doctor or hospital, whichever was first)
Section 6: Household Income
If seeking payment of hospital bills, the following information is needed to determine eligibility for the Hospital Care Assurance Program.
Section 7: Other/Collateral Sources
All bills must be submitted to insurance or benefit plans before compensation can be considered.
Section 8: Employment Information
Complete if filing for loss of earnings.
Section 9: Attorney Information
* I understand that if I get money from any other source to cover the same expenses paid through the Crime Victims Compensation Program, I must reimburse the state of Ohio that amount of money. (R.C. 2743.72)
I hereby authorize any person (including any physician, medical facility, or health care provider), employer organization, the Ohio Department of Job and Family Services or Child Support Enforcement Agency (for purposes of child support enforcement), law enforcement agency, or government agency, upon request, to release to the Ohio Attorney General, the Court of Claims of Ohio, or to my attorney, a copy of any report, document, record, criminal record, or other information (including tax information or returns, or medical information) in any way relating to my claim for an award of reparations under the Ohio Victims of Crime Compensation Program.
I understand that failing to provide my Social Security number may significantly impede the processing of my claim. I understand that medical records may contain information regarding care of psychiatric/psychological conditions, drug or alcohol abuse, HIV test results, AIDS, and AIDS-related conditions.
I understand that disclosure of confidential information from medical records may be protected by state or federal law. If applicable, state law (R.C. 3701.243) and federal regulations (42 C.F.R. part 2) prohibit the Ohio Attorney General or the Court of Claims of Ohio from making any further disclosure of confidential information without my specific written consent or as otherwise permitted by such regulations. I understand that I may revoke this authorization in writing submitted at any time to the Ohio Attorney General, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate two years from the date of my signature. I understand that the information I have provided is being relied upon as truthful and accurate.
I swear or solemnly affirm under penalty of law that all information provided by me or on my behalf is true and accurate to the best of my knowledge and belief.
Before submitting your application, please review all fields for accuracy.
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