Form OJP-7390/5 Crime Victim Compensation State Certification Form

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Overview

Form (7390,5)
Instructions

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Sheet 1: Form (7390,5)

																							Approved OMB No: 1121-0170 Expires: 02/28/2009
												U.S. Department of Justice
												Office for Victim of Crime	Office for Victims of Crime
					CRIME VICTIM COMPENSATION STATE CERTIFICATION FORM
								State of
					Reporting Period: October 1,								2005		through September 30,							2006
					NOTE: Please read the instructions on the Attached Page Before Completing this Form
	Part I: PAYMENT INFORMATION															Part II:			FUNDS AVAILABLE FOR THE STATE
																			VICTIM COMPENSATION PROGRAM
																			(During the Reporting Period)
	A:	Total Amount paid to or on behalf of crime														A:	Funds From All Sources Other Than VOCA Grant Funds
		victims from ALL FUNDING SOURCES															1.	General Funds											$	0.00
		(both State and Federal)								(+)		$	0.00				2.	Court Costs											$	0.00
																	3.	Fees											$	0.00
	B.	Amounts To Be Deducted From Total Paid															4.	Fines and Penalties											$	0.00
		to Crime Victims															5.	Private Donations											$	0.00
																	6.	Bond Forfeitures											$	0.00
		1.	Voca Grant Funds,			FY		FY				$	0.00				7.	Subrogation Recoveries											$	0.00
		2.	Subrogation Recoveries									$	0.00				8.	Restitution Recoveries											$	0.00
		3.	Restitution Recoveries									$	0.00				9.	Refunds											$	0.00
		4.	Refunds									$	0.00				10.	Reimbursements											$	0.00
		5.	Amount Awarded for Property									$	0.00				11.	Earned Interest											$	0.00
		6.	Other Reimbursements														12.	Reserves Carried Over											$	0.00
			Specify:									$	0.00				13.	Other Sources
												$	0.00						Specify:										$	0.00
																													$	0.00
	C.	Total Amount To Be Deducted
		(Sum of B1 through B6)								(-)		$	0.00			B.	Total Amount of Lines A1 through A13											(+)	$	0.00
	D.	Subtract Line C From Line A								(=)		$	0.00			C.	VOCA Grant Funds,					FY	-	FY	-			(+)	$
	E.	Recovery Costs, If Any														D.	Total Funds Received
		(Attach Documentation)								(+)		$	0.00				(Add Lines B and C)											(=)	$	0.00
	F.	Total State Payments Eligible for Matching
		VOCA Grant Award
		(Add Line D and Line E)								(=)		$	0.00
	Part III: CERTIFICATION
		I certify that the amount reported in Part I F of this form is complete and accurate.
		Type Name and Title of Duly Authorized Official
		Signature of Duly Authorized Official																								Date
	Note: This form must be signed by the authorized individual within the agency designated by the Governor to administer
			the VOCA crime victim compensation grant.
OJP Admin. Form (7390/5) (Rev. 4/99)

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Sheet 2: Instructions

CRIME VICTIM COMPENSATION STATE CERTIFICATION FORM
INSTRUCTIONS
The Crime Victims Compensation State Certification Form must be used by each state and territory submitting an application for Victims of Crime Act (VOCA) crime victim compensation grant funds. The amount certified in Part I, line F will be used by the Office of Victims of Crime (OVC) to determine the annual VOCA grant award. State payments must be reported for the Federal Fiscal Year (October 1 through September 30).
PART I:
Line A.	Please record the total amount of payments made by the compensation program to, or on behalf of, victims of crime from all funding sources. This amount may include payments for forensic sexual assault examinations including payments made in connection with a compensation claim or through a separate payment process. Do not include amounts expended for administrative costs in this figure.
Line B1 - B6.	Please record all amounts to be deducted from the total funds paid to crime victims.
	B1	Enter the total amount of VOCA grant funds used to pay compensation claims as reported on Line A. If funds from more than one grant were expended, enter the applicable grant years in the spaces provided. Do not include amounts expended for administrative costs.
	B2	Enter amounts recovered through civil suits or third party settlements. You do not need to include amounts expended for collection costs, such as attorney fees charged in connection with subrogation recoveries and service fees paid on wage garnishments.
	B3	Enter amounts of restitution recovered by your program, including reimbursements recovered for sexual assault examinations as well as compensation claims.
	B4	Enter amounts paid to crime victims and/or providers that are returned to the compensation program or never cashed.
	B5	Enter amounts awarded to crime victims for property damage or losses. Crime scene clean up, replacement costs for clothing and bedding held as evidence, and building modifications care compensable expenses that may be included in the annual certification, and should not be deducted as property damages or losses.
	B6	Enter all other reimbursements.
Line C.*	Please record the total of B1 through B6.
Line D.*	Please record the total of all payments made to victims with state funds less all required reductions.
Line E.	Recovery costs that may be claimed as a credit are limited to a percentage of those salaries incurred by the state compensation program which are specifically attributable to securing recoveries for crime victim claims. For a state program to qualify for the credit, they must verify that they have a staff person who dedicates at least 75% of his or her time to activities that are directly related to the recovery of crime victim restitution, subrogation, and refunds (RSR's). After calculating the percentage of each staff person's time that is dedicated to recovery of RSR's (75% or more), calculate this percentage of their annual salaries. Enter the total dollar amount. Please attach supporting documentation, such as time sheets, job descriptions, etc.
Line F.*	Please record the total eligible payments to victims of crime from state funding sources. Upon review and approval by the OJP Office of the Comptroller, your Federal grant award will equal 40% of this figure.
Part II:
Line A1-13.**	Report funds, other than VOCA grant funds, that were available to the state crime victim compensation during the reporting period. All amounts reported in Part I should also be reported in this section. Report funds carried over from a prior year on Line A-12.
Line B.*	Please record the total of A1 through A13.
Line C.***	Enter the total amount of VOCA victim compensation funds available to the program. This amount may include more than one VOCA grant award and may be greater than the amount reported in Part I (B) 1.
Line D.*	Enter the total revenue received from all sources. This figure represents the total available to the crime victim compensation program during the reporting period to pay crime victim compensation claims.
Part III:
The Crime Victim Compensation State Certification Form must be signed by the duly authorized official. This may be the Governor, Attorney General, Treasurer, Secretary of State, or another individual designated to administer the compensation program by the Governor. The Crime Victim Compensation State Certification Form must be signed by the duly authorized official. This may be the Governor, Attorney General, Treasurer, Secretary of State, or another individual designated to administer the compensation program by the Governor.
Public Reporting Burden
Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. The estimated average time to complete and file this information is 60 minutes or 1 hour. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the State Compensation and Assistance Division, Office for Victims of Crime, U.S. Department of Justice, 810 7th Street, N.W. Washington D.C. 20531
* If using the excel spreadsheet, these fields are calculated and automatically populated.
** If using the excel spreadsheet, fields A7, A8, A9, & A10 are automatically populated based on data inputs from Part I.
***If using the excel spreadsheet, the FY fields are automatically populated based on data inputs from Part I.
Also, entering spaces (hitting the space bar) in the fields causes errors in the calculation. If this occurs, go to the field and hit the "delete" key.