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Case Number: |
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| Full Address: |
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State V. |
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| Phone (Home): |
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Case Coordinator: |
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I. Property Stolen or
Damaged
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1. What property was
stolen or damaged as a result of this crime?
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2. What was the total
value of the stolen or damaged property?
(Please attach bills, receipts, cancelled checks,
estimates)
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3. What was the cost
of replacement or repairs? (Please attach bills, receipts,
cancelled checks, estimates)
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4. Do you have insurance
that paid for the stolen or damaged property? If so, please
list the amounts received and give the name and address
of your insurance company and agent.
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II. Physical Injury
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1. If you suffered
any physical injury or disability as a result of this crime,
please describ your injuries.
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2. If you were hospitalized
because of your injuries, please give the name of the hospital,
attending physician, and the length of your hospital stay.
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3. If you received
outpatient treatment for your injuries, please give the
name of the physician or hopsital and duration and type
of treatment.
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4. What were your
total medical expenses? (Please attach bills, receipts,
cancelled checks, estimates)
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5. Do you have medical
insurance that paid for your medical treatment and hospitalization?
If so, please list the amounts received and give the name
and address of insurance company and agent.
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6. If your injuries
caused you to miss time from work, please indicate how
much time you missed and how much money was lost in wages.
Also, please give the name, address and telephone number
of your employer.
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7. If you received
sick leave pay for the days you missed from work, please
indicate total number of days and total amount of sick
pay received.
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8. If you expect to
have any future medical expenses (outpatient therapy, prescription
drugs, etc.), please describe those expenses and state
whether your insurance will pay for them.
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III. Emotional
Injury
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1. Were you psychologically
injured? If so, please describe the emotional impact this
crime has had upon you and your family and any resulting
changes that have occurred.
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2. As a result of
this crime, have you or your family received any counseling
or therapy? (Please attach bills, receipts, cancelled checks,
estimates)
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3. Please describe
any other effects that being a victim of a crime has had
upon you or your family.
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