State of California Victim Compensation Board Form VCGCB-VCP-005 (Rev. 10/2017) [ENG] Page 1 of 7
Application For Crime Victim Compensation
Associated Application ID
(Enter if known)
Section 1: Claimant
A separate application must be led for each person seeking assistance.
Section 1 must be completed for all applications. The claimant is the person who has expenses
or is seeking assistance as a result of a crime. If you are ling this application on behalf of
someone else, put his/her information in Section 1 and your information in Section 3.
Preferred Spoken Language
Preferred Written Language
First Name Middle Name Last Name Gender
Relationship to Victim Social Security Number (SSN)
No SSN
Date of Birth
From the date of the crime to now, has the
claimant been in prison, on probation, on
parole or post-release community supervision
because of a felony?
Is the claimant required to
register as a sex offender?
Mailing Address
Street Number and Name or PO Box
Address 2 (Apartment or Unit #) City State Zip
Best Contact Number
Best Contact Number
Extension
Extension
E-mail E-mail Type
Check this box if you are a parent/guardian applying on behalf of a minor witness to
violent crime. Minor witnesses are eligible for mental health treatment only. Claimant is
under age 18, a witness in close proximity to a violent crime, but is neither the crime victim
nor related to the victim. Provide available victim, crime or other information in remaining
sections.
If you are an adult victim and the
expenses are for you, skip to Section 4.
If not, continue to Section 2.
Section 2: Crime Victim
The crime victim is the person who was injured, threatened with injury, or killed due to the crime.
First Name Middle Name Last Name Gender
Social Security Number (SSN)
No SSN
Date of Birth If victim is deceased, date of death
From the date of the crime to now, has the
victim been in prison, on probation, on
parole or post-release community supervision
because of a felony?
Is the victim required to
register as a sex offender?
Mailing Address
Street Number and Name or PO Box
Address 2 (Apartment or Unit #) City State Zip
E-mail E-mail Type
If you are completing this application on behalf of a minor or an incapacitated adult, continue to Section 3.
If not, skip to Section 4.
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Self (I am the victim)Paying the Deceased Victim's Crime-Related ExpensesVictim's ChildVictim's ParentVictim's Adoptive ParentVictim's SpouseVictim's Brother or SisterVictim's GrandparentVictim's GrandchildVictim's Foster ParentVictim's Legal GuardianLiving in the Household of the VictimPreviously Lived in Household of the VictimFamily Member that Witnessed the CrimePrimary Caretaker of VictimOther
YesNo
YesNo
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PersonalWork
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State of California Victim Compensation Board Form VCGCB-VCP-005 (Rev. 10/2017) [ENG] Page 2 of 7
Section 3: Parent or Guardian (Applicant)
This section is for parents or guardians of minors or incapacitated adults in Section 1.
Preferred Spoken Language
Preferred Written Language
Please indicate your relationship to the person listed in Section 1:
First Name Middle Name
Last Name Gender Social Security Number (SSN)
No SSN
Date of Birth
From the date of the crime to now,
have you been in prison, on probation,
on parole or post-release community
supervision because of a felony?
Are you required to register
as a sex offender?
Mailing Address
Street Number and Name or PO Box
Address 2 (Apartment or Unit #) City State Zip
E-mail E-mail Type
Continue to Section 4.
Section 4: Information About Your Expenses
For the victim of the crime, the following benets may be available. Please check the crime-related expenses you are
requesting. Please attach copies, or a list, of any crime-related bills.
Medical and/or dental expenses
Moving or relocation expenses
Job retraining
(for a victim disabled because of the crime)
Mental health treatment
Home security improvements
Crime scene clean-up
Income loss
(if you missed work because of the crime)
Home or vehicle modications
(for a victim disabled because of the crime)
Mileage reimbursement or transportation
costs
Other crime-related expenses
For someone other than the victim of the crime, the benets below may be available. Please check the crime-related
expenses you are requesting. Please attach copies, or a list, of any crime-related bills.
For minor witnesses to violent crime, only mental health benets are available. Proceed to Section 5.
Mental health treatment
Funeral and/or burial expenses
Medical expenses for a deceased
victim
Wage loss
(up to 30 days if a minor dies or is hospitalized)
Crime scene clean-up
Loss of support
(for dependents of a deceased or disabled victim)
Home security improvements
Emergency Award Request
Emergency awards may be requested in certain situations. An emergency award is intended to pay for crime-related expenses in cases where you will suffer
serious nancial hardship if crime-related expenses are not immediately paid. Substantial hardship means you would not have any money left for necessities like
food or rent after you paid for crime-related bills. Qualifying emergency awards are generally paid within 30 calendar days of receipt of the application.
I am requesting an emergency award.
Best Contact Number Extension
Claimant's ParentClaimant's Adoptive ParentClaimant's Legal GuardianClaimant's Social WorkerClaimant's SpouseClaimant's Brother or SisterClaimant's ChildClaimant's GrandparentClaimant's GrandchildClaimant's ConservatorClaimant's Court-Appointed AttorneyClaimant's Guardian Ad LitemClaimant's Probation OfficerPrimary Caretaker of ClaimantOther
YesNo
YesNo
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State of California Victim Compensation Board Form VCGCB-VCP-005 (Rev. 10/2017) [ENG] Page 3 of 7
Section 5: Crime Information
Law Enforcement Agency Name
If reported to law enforcement, name of the law enforcement agency
Dates Crime Occurred
From To
Date Crime was Reported Crime Report Number Describe Injuries
Person who committed the crime (suspect), if known
Suspect unknown
First Name Middle Name Last Name
Location of Crime (if known)
Address, Intersection, Area, etc.
Address 2 (Ste. #) City State Zip
County
Type of Crime
Section 6: Representative Information (A representative is not required to apply for compensation.)
This section is for representatives only. Victim Witness Assistance Center Advocates need only provide phone, name, center #,
sign and date. All other representatives, please ll out this section completely.
Please indicate your relationship
to the person listed in Section 1:
If other, please indicate:
First Name Middle Name Last Name Telephone Extension
Organization Name
Mailing Address
Street Number and Name or PO Box Address 2 (Suite #)
City State Zip
For Victim Assistance Center Staff Only
JP/VWC Number
For Attorneys Only
I am requesting payment pursuant to
Government Code Section 13957.7(g).
Tax ID State Bar Number
Telephone E-mail
Signature and Date Required for all Representatives
Representative’s Signature Date
Section 7: How Did You Find Out About the Board?
Law Enforcement
Adult Protective Services
Billboard or Poster
District Attorney
Mental Health Provider
Card or Booklet
Medical Provider
Victim Witness Assistance Center
Children’s Protective Services
Media (TV, Radio, Newspaper, etc.)
Other
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AlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYuba
ArsonAssault or BatteryAssault with a Deadly WeaponCarjacking (Vehicular)Child AbuseChild MolestDomestic ViolenceDriving Under the InfluenceElder AbuseHit and Run (Vehicular)HomicideHomicide (Vehicular)KidnappingRapeRobberySexual AssaultStalkingTerrorismThreatsOtherDo not know
AttorneyVictim Witness AdvocateCommunity-Based AdvocateSpouseParentFamily MemberFriend
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State of California Victim Compensation Board Form VCGCB-VCP-005 (Rev. 10/2017) [ENG] Page 4 of 7
Section 8: Federal Reporting Information
The following voluntary information is for the person receiving compensation and is used for statistical purposes only to comply
with federal regulations.
Ethnicity
American Indian/
Alaska Native
Asian
Black/African
American
Hispanic
or Latino
Native Hawaiian and
Other Pacic Islander
White Non-Latino/
Caucasian
Other Race
Multiple
Races
Decline to State Other
Is the victim disabled? Was the victim disabled prior to the crime?
Section 9: Insurance Information
Please list your insurance information below. The California Victim Compensation Board (CalVCB) is the payer of last resort. We
may contact your insurance company as a potential reimbursement source.
I have no insurance of any kind.
Health Insurance
Medi-Cal Benets Identication Card Number Issue Date
Health Insurance Company Name Policy Number Group Number Telephone Ext.
Mailing Address
Street Number and Name or PO Box Address 2 (Suite #) City State Zip
Name of Insured
First Name Middle Name Last Name
Have you led an insurance claim related
to this crime?
Auto/Vehicle Insurance (Includes car, truck, motorcycle, motorhome, boat, jet ski, airplane, etc.)
Complete if the crime involves a vehicle, including pedestrians hit by a vehicle.
Auto Insurance Company Name Policy Number Telephone Ext.
Mailing Address
Street Number and Name or PO Box Address 2 (Suite #) City State Zip
Name of Insured
First Name Middle Name Last Name
Have you led an insurance claim related
to this crime?
Other Insurance
Please check any additional insurance sources that could be applied to your application.
Medi-Cal Medicare Workers’ Comp Other
If you have more than one insurance provider,
please list on a separate piece of paper and mail with your application.
YesNo
YesNo
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State of California Victim Compensation Board Form VCGCB-VCP-005 (Rev. 10/2017) [ENG] Page 5 of 7
Section 10: Employer Information
Please list the victim’s employer. If you are a parent/guardian seeking wage loss benets because a minor victim was
hospitalized or is deceased, list your employer.
Employer’s Business Name
Contact Person
First Name Last Name Telephone Ext.
OK to contact
employer?
Mailing Address
Street Number and Name or PO Box Address 2 (Suite #) City State Zip
Is or was the victim self-employed? Did the victim miss work as a result of crime-related injuries?
Did the crime occur while the victim was on the job or at the workplace?
If you have more than one employer,
please list on a separate piece of paper and mail with your application.
Section 11: Civil Suit Information
If you decide to le a civil suit, by law, you are required to notify CalVCB within 30 days of ling the action.
Have you led, or do you plan to le, a civil suit related to this crime?
Attorney’s Name
First Name Middle Name Last Name Telephone Extension
Mailing Address
Street Number and Name or PO Box Address 2 (Suite #) City State Zip
Your application for crime victim compensation is almost complete.
• After entering all available information, print the application.
• Attach copies of any documentation that supports your application for crime victim compensation, including copies of crime-
related bills, insurance, or anything relating to the crime. Save original documents for your records.
• Please read the next page carefully, sign and date, and send to the address indicated or deliver to your local Victim Witness
Assistance Center.
• CalVCB will send you a letter acknowledging that your application has been received. The acknowledgment letter will include
additional information about the benets requested on your application.
• A CalVCB representative may contact you for additional information if you were not able to provide it with your application.
• For any questions about victim compensation, you can contact your local Victim Witness Assistance Center or call CalVCB at
1-800-777-9229.
YesNo
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State of California Victim Compensation Board Form VCGCB-VCP-005 (Rev. 10/2017) [ENG] Page 6 of 7
This page must be signed and dated.
Section 12: Information Release
I give permission to any healthcare provider; any medical biller, any funeral director or similar persons, any employer, any police or other government agency, including the Department
of Justice, the Social Security Administration, the State Franchise Tax Board, and the Federal Internal Revenue Service; any insurance company; or any other person or agency, to
provide information relating to this application, including medical (including, but not limited to history or physical records, consultation reports, pathology reports, discharge summaries,
operative reports, X ray and other radiology reports, laboratory reports, chart notes, narrative reports, and billing records), mental health, and felony conviction records, to the California
Victim Compensation Board (CalVCB) or its representatives, for the purpose of determining eligibility for CalVCB benets. This permission also applies to all sources of recovery
for the claimed losses, including but not limited to, health or medical benets, unemployment or disability benets, Social Security benets (Social Security disability, Supplemental
Security income, and/or retirement, including the supporting medical and/or mental health records), and Veteran benets. I also give permission for the release of federal and state tax
information, including tax returns, for the purpose of verifying income. I hereby waive all legal privileges to any of this information required by CalVCB regarding my claim.
I agree that a photocopy or fax of this signed form is as valid as the original, and my signature gives permission for the release of all specied information.
I agree that CalVCB or its representatives may pursue restitution from the convicted offender in this matter to recover monies paid to me by CalVCB and that by ling this application I
have authorized use of information in this application and subsequent claim les to pursue restitution from the convicted offender.
In order to verify or process this application, I agree that CalVCB or its representatives may provide information about this application, and the information contained in this application,
to any representative named on this application, government agency, or health care provider or other provider of services, and may pay the provider directly if payment of these services
is approved.
I agree that I may revoke this authorization at any time. The revocation must be in writing. The revocation will take effect when CalVCB receives it, but I may be deemed ineligible for
CalVCB benets once the revocation is received by CalVCB. However, no healthcare provider may condition treatment, payment, enrollment or eligibility for benets on whether I sign
this authorization. I am entitled to a copy of this authorization except in limited circumstances. I agree that information disclosed under this authorization may be redisclosed by the
recipient as required by law and this redisclosure may no longer be protected by federal or state law.
I agree that the authorizations and agreements herein will expire ten (10) years after the date of my signing this form.
Signed Date
(Parent or guardian must sign if victim is a minor or incapacitated.)
Section 13: My Agreement to the California Victim Compensation Board
As required by California law, I will contact and repay the California Victim Compensation Board (CalVCB) if I, or anyone on my behalf, receives any payments from the offender, a civil
lawsuit, an insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt of benets from CalVCB, in the
amount of the total benets granted by CalVCB. I understand I may be responsible for repaying CalVCB any amount for which it is later determined that I was not eligible. I will notify
CalVCB if I hire an attorney to represent me in any action related to this crime or if I pursue any action on my own.
Any monies I receive from CalVCB for moving/relocation expenses, improving home security, or for modifying a home or vehicle for a disabled victim will be used only for those
purposes. If I am a victim of domestic violence receiving moving/relocation expenses, I will not tell the offender my home address nor allow the offender on the premises at any time, or I
will seek a restraining order against the offender.
In the event that I am compensated for any pecuniary loss by CalVCB and the State of California subsequently receives compensation for the same loss on my behalf from the
perpetrator (including any monies received through a restitution order) or from any other source, I hereby assign to the Victim Compensation Board any and all rights to such duplicate
compensation.
I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my knowledge and belief.
I understand that I may be found to be ineligible for benets, and that action may be taken to recover benets I receive if I provide information that is false, intentionally incomplete, or
misleading.
Signed Date
(Parent or guardian must sign if victim is a minor or incapacitated. County social workers, see section 13a.)
Printed Name
Section 13a: For County Social Workers Only
As required by California law, I will contact and inform the California Victim Compensation Board (CalVCB) if I learn the claimant receives any payments from the offender, a civil lawsuit,
an insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt of benets from CalVCB.
I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my knowledge and belief.
I understand that the claimant may be found to be ineligible for benets, and that action may be taken to recover benets the claimant receives if the claimant provides information that
is false, intentionally incomplete, or misleading.
Signed Date
Printed Name
Mail completed application to:
California Victim Compensation Board
PO Box 3036, Sacramento, CA 95812-3036
or
deliver to your local Victim Witness Assistance Center
For more information call:
1-800-777-9229
Hearing impaired, please call the
California Relay Service (711)
victims.ca.gov Helping California Crime Victims Since 1965
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Privacy Notice on Collection
1. CalVCB collects this information based on California Government Code sections 13952 et seq. and 13954.
2. All information collected from this site is subject to, but not limited to, the Information Practices Act. See http://victims.ca.gov/
media/pra.aspx.
3. This information is collected for the purpose of determining eligibility for compensation.
4. CalVCB may disclose your personal information to another requestor, only if required to do so by law or in good faith that
such action is necessary to:
a. Conform to the edicts of the law or comply with legal process served on CalVCB or the site;
b. Protect and defend the rights or property of CalVCB; and,
c. Act under exigent circumstances to protect the personal safety of users of CalVCB, or the public.
5. Individuals are to provide only the information requested.
6. The information provided is mandatory.
7. The consequences of not providing the requested information could result in the denial of your application.
8. You have the right to access the records containing the personal information that you provided.
9. The information collected is used by the California Victim Compensation Board.
10. Any questions regarding the information collected, please write to the following address: PO Box 48, Sacramento, CA 95812,
email [email protected], call (800) 777-9229, or contact the CalVCB Privacy Coordinator at InfoSecurityandPrivacy@
victims.ca.gov.
11. For additional information regarding privacy, please see CalVCB’s Privacy Notice. See http://victims.ca.gov/privacy.aspx.
12. For information regarding consumer information on security, please visit https://oag.ca.gov/privacy/online-privacy.
