Victims Compensation Forms

Appeal Request (PDF, 49.13 KB)
Billing Tab Guide for the Victims Comp Portal (PDF, 1.04 MB)
Certificate of Foreign Status of Beneficial Owner (W-8BEN) (PDF, 4.76 MB)
Civil Rights Requirements Form (PDF, 255.46 KB)
Claims Investigator Contact Roster (PDF, 170.8 KB)
CPT Code Description of Services Reference Sheet (PDF, 184.34 KB)
Crime Victims Compensation Application Spanish (PDF, 53.18 KB)
Crime Victims Compensation Application (PDF, 107.49 KB)
Deceased Victim Employment Verification Form (PDF, 236.18 KB)
District Attorney Release Form (PDF, 539.93 KB)
Employment Verification Form For Loss of Support (PDF, 193.02 KB)
Employment Verification Form for Lost Wages (PDF, 298.91 KB)
FI and FME Victims Compensation Division Designee Form (PDF, 533.47 KB)
Forensic Medical Exam CPT Code Reference Sheet (PDF, 208.03 KB)
Forensic Medical Examination Law Enforcement DFCS Verification Form (PDF, 580.83 KB)
Forensic Medical Examination Fee Schedule (PDF, 233.77 KB)
Forensic Medical Examination Law Enforcement- DFCS Verification Form (Fillable) (PDF, 176.65 KB)
Human Trafficking Reimbursement Form (PDF, 229.83 KB)
Itemized Bill Example (PDF, 260.07 KB)
Medical Release Form (PDF, 276.38 KB)
Minor Beneficiary Form in Spanish (PDF, 188.7 KB)
Minor Beneficiary Form (PDF, 695.58 KB)
Prosecuting Attorney's Questionnaire (PDF, 299.56 KB)
Serious Mental and Emotional Trauma (SMET) Form (PDF, 117.71 KB)
Supplier Change Request Form (PDF, 903.3 KB)
Taxpayer Identification Number and Certification Form (W-9) (PDF, 45.82 KB)
Victims Comp FAQ for Restitution (PDF, 932.33 KB)
Victims Comp FAQ (PDF, 865.29 KB)
Victims Comp Portal Offender Restitution Feature (PDF, 496.49 KB)
Victims Comp Portal Rack Card (PDF, 602.55 KB)
Victims Comp Portal Resource Guide (PDF, 2.3 MB)
Work Release Form (PDF, 208.39 KB)