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DOCR
Crime Victim Compensation Application
Crime Victim Compensation Application
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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
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
