| Full Name: | _______________________ | Date of Crime: | ____________________________ |
| Law Enforcement Agency: _____________________________________________________ |
| Responding Officer/ Badge Number: _____________________________________________ |
| Crime Report Number: _______________________________________________________ |
| Telephone:_________________________________________________________________ |
| Detective/Investigator: | _____________________ | Telephone: | _______________________ | Victim Advocate: | _____________________ | Telephone: | _______________________ | Prosecuting Attorney: | _____________________ | Telephone: | _______________________ | D. A. Investigator: | _____________________ | Telephone: | _______________________ | Probation Officer: | _____________________ | Telephone: | _______________________ | Superior Court Judge: | _____________________ | Telephone: | _______________________ |
| Victim Compensation and Government Claims Board Telephone: | 1-800-777-9229 or (916) 322-4426 |
| Local Joint Powers Claim Unit Telephone: | __________________________________________ |
| VOC Claim Number: Date Claim Filed: | __________________________________________ |
| Attorney Name/Number (if applicable): | __________________________________________ |
| Creditor/Date of Service | Amount | |
Bills Submitted on VOC Claim:
|
____________________ | ____________________ |
| ____________________ | ____________________ | |
| ____________________ | ____________________ | |
| ____________________ | ____________________ |
| Insurance Company | Policy Number | ||
| Health: | ____________________________ | ____________________________ | |
| Automobile: | ____________________________ | ____________________________ | |
| Homeowner's: | ____________________________ | ____________________________ | |
| Life: | ____________________________ | ____________________________ | |
| Other: | ____________________________ | ____________________________ |
