California Code of Regulations, Title 2, § 649.7. Complete Application
- The applicant provides all information as directed in the instructions to, and as elicited on, the application which the Board shall require to be certified under penalty of perjury or upon information and belief. As part of the application the Board shall require the following information:
- The name, residence address, and if different, mailing address, date of birth and telephone number of the applicant seeking restitution from the Fund.
- A designation as prescribed on the application as to whether the applicant is a victim or derivative victim, or in the event of a death caused by a crime, a person who legally assumed the obligation, or who voluntarily paid the medical or burial expenses incurred as a direct result of the qualifying crime (Section 13957(a)(9)(A) and (C) of the code).
- If the person signing the application as the applicant is a person other than the actual victim or derivative victim seeking assistance, some designation as to the legal authority of such person to apply for benefits on behalf of the victim or derivative victim (e.g. parent or legal guardian for a child; or court appointed conservator for adults adjudicated to be incompetent.)
- A description of the date, nature, location, and circumstances of the qualifying crime.
- Except in the case where the applicant has no pecuniary loss, a complete statement of losses and reimbursements directly related to the qualifying crime including but not limited to the cost of medical care or burial expense, the loss of wages the victim has incurred to date, or the loss of support the derivative victim has incurred to date, for which they claim assistance. This statement must include the date or dates that medical, mental health or other professional services were provided to the victim or derivative victim and a description of the services provided along with a statement that the services were in fact received and that such services were required as a direct result of the qualifying crime and for no other reason. If mental health counseling or psychotherapy services were provided, the statement must include a designation as to whether any counseling or psychotherapy provided was in an individual, family or group; setting.
- A signed authorization permitting the VCP or a joint powers victim witness center, or both, to verify the contents of the application.
- If the applicant is represented by an attorney or other authorized person, the name, address and telephone number of such representative. If the representative is an attorney, the California State Bar license number and the tax payer identification number.
- A statement whether the victim, the victim's survivors, or the derivative victim have commenced or intend to commence a civil action to recover monetary damages from the perpetrator or perpetrators of the qualifying crime or any other parties in connection with the qualifying crime, along with the name, telephone number and address of any attorney representing the applicant in such civil proceedings.
- A promise to contact and repay the VCP if the applicant receives any payments from the offender, a civil suit, an insurance policy, or any other governmental or private agency to cover expenses that the VCP has already paid.
- A statement disclosing all collateral benefits including any private or public insurance or benefits payable from private or public programs of assistance for which the victim, the victim's survivors, or the derivative victim have applied or for which they may be eligible.
- In addition to the information as specified in subparagraph (a) above, applicants seeking types of assistance as set forth in Section 13957 of the code shall provide the following information relative to each category of assistance claimed:
- If medical or mental health expenses are claimed to have been incurred as a direct result of the qualifying crime, an itemized statement from the professional provider for all medical or mental health expenses incurred as of the date of the application including the license number of the professional certificate issued by the State of California or other jurisdiction to the medical or mental health practitioner providing the service as well as his or her business address and telephone number. Providers of services who are authorized by law to offer such services as part of their on-going business activity, but who are not required to obtain a professional or occupational license must provide either their social security number, or their Federal Employer Identification Number. The VCP may require the submission of mental health treatment session or progress notes in order to determine whether the treatment will best aid the victim or derivative victim and is necessary as a direct result of the qualifying crime. Session notes will be kept in a confidential locked file and after review, shall be returned to the provider or destroyed by the VCP upon request of the treating provider.
- If loss of income is claimed to have occurred as a direct result of the qualifying crime, the applicant shall produce evidence of income loss as well as a statement of disability from the treating medical or mental health provider.
- If funeral or burial expenses are claimed as a direct result of the qualifying crime, an itemized statement for all funeral or burial expenses incurred.
- If rehabilitative services are claimed, the applicant shall produce that evidence of need, and documentation for rehabilitation as specified in Section 649.24(c) of these regulations.
- A copy of the crime report evidencing the commission of the qualifying crime and setting forth the circumstances and factual events surrounding it.
In order to expedite the processing of the application, applicants will be encouraged to obtain and submit, along with the application, a copy of the crime report as prepared by the law enforcement agency to which the qualifying crime was reported. In cases in which the applicant or his or her representative are unable or decline to obtain such crime report, VOC or joint powers victim witness centers shall obtain the crime report.
No application shall be deemed complete until VOC or its contract agencies have received a copy of the crime report, unless VCP staff is otherwise able to verify that a qualifying crime occurred.
- All applications and supplemental claims must be certified under penalty of perjury by the victim or derivative victim where the victim or derivative victim is the applicant, or shall be attested to under information and belief if completed by an applicant other than the victim or derivative victim, or by an authorized representative.
Note: Authority cited: Section 13974, Government Code. Reference: Sections 13951, 13952, 13952.5, 13954, 13956, 13957, 13957.2, 13957.5, 13957.7 and 13963, Government Code.
- Change without regulatory effect repealing former Section 649.7, and renumbering and amendment of Section 649.14 to Section 649.7 filed 9-28-87; operative 10-28-87 (Register 87, No. 41).
- Change without regulatory effect pursuant to Title 1, California Code of Regulations, Section 100(b)(3) filed 2-16-90 (Register 90, No. 9).
- Change without regulatory effect renumbering former section 649.7 to section 649.35 and renumbering former section 649.9 to section 649.7, including amendment of section and Note, filed 12-6-2007 pursuant to section 100, title 1, California Code of Regulations (Register 2007, No. 49).
- Amendment of section and Note filed 6-12-2009; operative 7-12-2009 (Register 2009, No. 24).
- Change without regulatory effect amending Note filed 12-27-2012 pursuant to section 100, title 1, California Code of Regulations (Register 2012, No. 52).