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West Virginia Crime Victims Compensation Fund
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West Virginia Crime Victims Compensation Fund
  • Victim Resources
  • Victim Service Providers
  • About Us

Crime Victims Compensation Fund Application

Step 1 of 2 – General

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CLAIMANT NAME(Required)
(The claimant is the individual filing the claim)

ADDRESS(Required)

MM slash DD slash YYYY
DOES THIS APPLICATION PERTAIN TO CIVIL JUVENILE ABUSE AND NEGLECT PETITION(Required)
IS THE CLAIMANT ALSO THE VICTIM?(Required)
(The claimant is the individual filing the claim)

CLAIMANT AS VICTIM

SEX(Required)
RACE
DID THE VICTIM KNOW THE SUSPECT(S)(Required)
INSURANCE AND REIMBURSEMENT SOURCES (Check all coverage types held by the victim at time of incident)
By law, you must first use all existing sources of financial assistance or reimbursement, including all insurance before receiving payment from the Crime Victims Compensation Fund.

VICTIM INFORMATION

Victim's Name(Required)
Victim's Date of Birth(Required)

Victim's Address(Required)
Victim's Sex(Required)
Victim's Race

DID THE VICTIM KNOW THE SUSPECT(S)(Required)
INSURANCE AND REIMBURSEMENT SOURCES (Check all coverage types held by the victim at time of incident)
By law, you must first use all existing sources of financial assistance or reimbursement, including all insurance before receiving payment from the Crime Victims Compensation Fund.

IS THE VICTIM DECEASED?(Required)

VICTIM'S DEATH INFORMATION

DATE OF DEATH(Required)

DID THE VICTIM HAVE ANY DEPENDENTS(Required)
A dependent is one who receives over half of his or her support from the crime victim. There can be multiple dependents per victim on a claim.

DEPENDENTS OF VICTIM

1ST DEPENDENT NAME
1ST DEPENDENT DATE OF BIRTH
2ND DEPENDENT NAME
2ND DEPENDENT DATE OF BIRTH

EMPLOYER INFORMATION

Was the Victim Employed on the Date of the Crime?
Did the Victim Lose Work Due to Injury?

Employer Address

ABUSE AND NEGLECT PROCEEDING

MINOR NAME(Required)
DATE OF BIRTH(Required)
(FOSTER PARENT, SOCIAL WORKER, ADVOCATE, GAL, ETC.)
OFFENDER(Required)
OFFENDER
OFFENDER
BRIEFLY DESCRIBE EVENTS LEADING UP TO THE PETITION BEING FILED
IS THERE ANOTHER MINOR YOU WOULD LIKE TO APPLY FOR?(Required)

ABUSE AND NEGLECT PROCEEDING MINOR 2

MINOR 2 NAME(Required)
MINOR 2 DATE OF BIRTH(Required)
(FOSTER PARENT, SOCIAL WORKER, ADVOCATE, GAL, ETC.)
OFFENDER(Required)
OFFENDER
OFFENDER
BRIEFLY DESCRIBE EVENTS LEADING UP TO THE PETITION BEING FILED

CRIME INFORMATION

DATE OF CRIME
DATE CRIME REPORTED

Please check the box that most closely describes the type of crime that occurred:
1ST SUSPECT'S NAME
ADULT / JUVENILE
2ND SUSPECT'S NAME
ADULT / JUVENILE

Describe the crime details – include names, locations, dates and events to the best of your ability.

COURT PROCEEDINGS

HAS THE SUSPECT(S) BEEN CHARGED?
COURT

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