You’re offline. This is a read only version of the page.
Toggle navigation
Sign in
Home
DOCR
Crime Victim Compensation Application
Crime Victim Compensation Application
0%
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
*
Gender
Female
Gender
Male
Address
*
*
City
*
*
State / Province
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ON
QC
NS
NB
MB
BC
PE
SK
AB
NL
ZIP / Postal Code
*
*
Telephone Number
*
*
Email Address
*
*
*
Race/Ethnic Background
*
American Indian/Alaska Native
Asian
Black African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White Non-Latino/Caucasian
Some Other Races
Multiple Races
