Forms

Appeal Request

Billing Tab Guide for the Victims Comp Portal

Civil Rights Requirements

Claims Investigator Contact Roster

CPT CODE/Description of Services Reference Sheet

Crime Victims Compensation Application

Crime Victims Compensation Application in Spanish

Deceased Victims Employment Verification Form

District Attorney Access Form

DUI Memorial Sign Application

DUI Memorial Sign Application (Fillable)

Employment Verification Form for Loss of Support

Employment Verification Form for Lost Wages

FI/FME Victims Compensation Division Designee Form

FME CPT Code Reference Sheet

FME Fee Schedule

FME Itemized Bill Example

Forensic Interview Application for Payment

Forensic Interview DFCS Verification Form

Forensic Interview Itemized Bill Example

Forensic Interview Law Enforcement Verification Form

Forensic Interview Referral Document – FIRD

Forensic Interview Referral Document – FIRD (Fillable)

Forensic Interviewer Funding Certification Document

Forensic Interviewer Funding Certification Document (Fillable)

Forensic Medical Examination Application for Child Advocacy/Rape Crisis/Sexual Assault Centers

Forensic Medical Examination Application for Hospital/Medical Centers

Forensic Medical Examination DFCS Verification Form

Forensic Medical Examination Fee Schedule

Forensic Medical Examination Law Enforcement Verification Form

Forensic Medical Examination Law Enforcement Verification Form (Fillable)

Human Trafficking Reimbursement Form

Itemized Bill Example

Medical Release Form

Minor Beneficiary Form

Minor Beneficiary Form in Spanish

Prosecuting Attorney’s Questionnaire

Serious Mental and Emotional Trauma (SMET) Form

Supplier Change Request Form

Taxpayer Identification Number and Certification Form (W-9)

Unclaimed Restitution Application for Business

Unclaimed Restitution Application for Business (Fillable)

Unclaimed Restitution Application for Individual Victim

Unclaimed Restitution Application for Individual Victim (Fillable)

Victims Bill of Rights

Victims Bill of Rights in Spanish

Victims Comp Portal Offender/Restitution Feature

Victims Comp Portal Rack Card

Victims Comp Portal Resource Guide

Work Release Form