Crime Victim Compensation Application · ND Apps Portal

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Section 1 - Victim Information

Complete this section for the person who was injured

Name of VICTIM (First)

*

Name of VICTIM (Last)

*

Date of Birth

*

Gender

FemaleMale

Address

*

City

*

State / Province

ZIP / Postal Code

*

Telephone Number

*

Email Address

**

Race/Ethnic Background