Supplemental Sheet
Section B-1: Victim Information
(All Applicants)
Known child(ren), dependent(s), or recipient(s) of victim’s support:
Name: ______________________________ DOB:__________ Relationship: ______________
Known child(ren), dependent(s), or recipient(s) of victim’s support:
Name: ______________________________ DOB:__________ Relationship: ______________
Known child(ren), dependent(s), or recipient(s) of victim’s support:
Name: ______________________________ DOB:__________ Relationship: ______________
Known child(ren), dependent(s), or recipient(s) of victim’s support:
Name: ______________________________ DOB:__________ Relationship: ______________
Known child(ren), dependent(s), or recipient(s) of victim’s support:
Name: ______________________________ DOB:__________ Relationship: ______________
Known child(ren), dependent(s), or recipient(s) of victim’s support:
Name: ______________________________ DOB:__________ Relationship: ______________
***********************************Section B-2***********************************
Do you know of anyone else who may be eligible for expense reimbursement under this program who is not party to this application? ____ Yes ____ No If Yes, please list:
Name: _________________________________ Relationship: _________________________________
Full Address: _________________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Name: _________________________________ Relationship: _________________________________
Full Address: _________________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Name: _________________________________ Relationship: _________________________________
Full Address: _________________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Name: _________________________________ Relationship: _________________________________
Full Address: _________________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Name: _________________________________ Relationship: _________________________________
Full Address: _________________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Supplemental Sheet
Section F: Collateral Sources
(All Applicants)
Please acknowledge any of the following sources of reimbursement or payment applied for or received in relation to this crime:
____ Medical/Health Insurance ____ Disability Insurance
____ Medicare/Medicaid ____ Vocational Rehabilitation Benefits
____ Property Insurance ____ Homeowners/Renters Insurance
____ Military/Veterans’ Benefits ____ Restitution
____ Payments/Compensation by Local, State, State VOCA, Federal, and/or Foreign Governments
____ Other (please list): ____________________________________________________
Have you previously received any funds from the Office for Victims of Crime or its Contractor?
____ Yes ____ No If Yes, how much? $______ For what? ________________________
Please provide additional information on all of the above sources checked or received/identified:
Source: ____________________________________ Policy No. (if applicable): ___________________
Company (if applicable): ________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Name of Individual Reimbursed: _____________________________ SSN: ______________________
Status of Application:
____ Application Pending
____ Application Approved; Amount __________
____ Application Denied. If declined, please indicate reason:___________________________________ ____________________________________________________________________________________
************************************************************************************
Please acknowledge any of the following sources of reimbursement or payment applied for or received in relation to this crime:
____ Medical/Health Insurance ____ Disability Insurance
____ Medicare/Medicaid ____ Vocational Rehabilitation Benefits
____ Property Insurance ____ Homeowners/Renters Insurance
____ Military/Veterans’ Benefits ____ Restitution
____ Payments/Compensation by Local, State, State VOCA, Federal, and/or Foreign Governments
____ Other (please list): ____________________________________________________
Have you previously received any funds from the Office for Victims of Crime or its Contractor?
____ Yes ____ No If Yes, how much? $______ For what? ________________________
Please provide additional information on all of the above sources checked or received/identified:
Source: ____________________________________ Policy No. (if applicable): ___________________
Company (if applicable): ________________________________________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Name of Individual Reimbursed: _____________________________ SSN: ______________________
Status of Application:
____ Application Pending
____ Application Approved; Amount __________
____ Application Denied. If declined, please indicate reason:___________________________________ ____________________________________________________________________________________
Supplemental Sheet
Section G: Service Provider Information
(Itemized and Supplemental Applicants Only)
Please supply the following information on person(s) and/or organizations that provided services related to the act of international terrorism to the victim. Please include all documentation of services received and related costs.
Name of service provider: _______________________________________________________________
Street address: ________________________________________________________________________
City/State/Zip: _______________________________ Country: ________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Type of assistance provided:_____________________________________________________________
Cost of service(s) rendered $________ Diagnosis or Condition: _______________________________
Are services ongoing? ____Yes ____ No If Yes, how long will services continue?________________
Were you billed for the cost of the services? ____ Yes ____ No
Were the costs paid in full? ____ Yes ____ No If Yes, full amount paid $__________________
Were the costs paid in part? ____ Yes ____ No If Yes, partial amount paid $________________
By whom were either the full or partial payments made? _______________________________________ ____________________________________________________________________________________
Name/Telephone/Fax/E-mail (optional)/Claim Number (if applicable)
******************************************************************************
Name of service provider: _______________________________________________________________
Street address: ________________________________________________________________________
City/State/Zip: _______________________________ Country: ________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): ________________________
Type of assistance provided:_____________________________________________________________
Cost of service(s) rendered $________ Diagnosis or Condition: ________________________________
Are services ongoing? ____Yes ____ No If Yes, how long will services continue?________________
Were you billed for the cost of the services? ____ Yes ____ No
Were the costs paid in full? ____ Yes ____ No If Yes, full amount paid $__________________
Were the costs paid in part? ____ Yes ____ No If Yes, partial amount paid $________________
By whom were either the full or partial payments made? _______________________________________ ____________________________________________________________________________________
Name/Telephone/Fax/E-mail (optional)/Claim Number (if applicable)
******************************************************************************
Name of service provider: _______________________________________________________________
Street address: ________________________________________________________________________
City/State/Zip: _______________________________ Country: ________________________________
Telephone: _______________ Fax: _______________ E-mail (optional): _________________________
Type of assistance provided:_____________________________________________________________
Cost of service(s) rendered $________ Diagnosis or Condition: _______________________________
Are services ongoing? ____Yes ____ No If Yes, how long will services continue?________________
Were you billed for the cost of the services? ____ Yes ____ No
Were the costs paid in full? ____ Yes ____ No If Yes, full amount paid $______
Were the costs paid in part? ____ Yes ____ No If Yes, partial amount paid $______
By whom were either the full or partial payments made? _______________________________________ ____________________________________________________________________________________
Name/Telephone/Fax/E-mail (optional)/Claim Number (if applicable)
[Last Updated: 08/24/06 baw]
File Type | text/rtf |
File Title | Supplemental Sheet |
Author | td50621a |
Last Modified By | walkerb |
File Modified | 2006-08-24 |
File Created | 2006-08-24 |