APPLICATION FOR COMPENSATION 1 SECTION A ... - Vintec

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TO BE COMPLETED IF IDENTITY OF OFFENDER UNKNOWN AT TIME OF APPLICATIONI………………………………………agree that if at any future time I become aware of the identity orwhereabouts of the person responsible for my injuries, I will notify the Director-General, Department ofJustice and Attorney-General immediately.Signed(please print full name)Witnessed(please print full name)Dated the …………….day of ………………….20 .NB That section 663E of the Criminal Code and section 38 of the Criminal Offence Victims Act 1995 provide thatshould you receive any payment from the offender, or become entitled, whether by an order of a court or by acompromise of action, to receive an amount of money in respect of the injury in relation to which this approval hasbeen given, that amount is charged by way of a first charge in favour of the Attorney-General and Minister for Justiceto the extent of the amount of the payment received by your client from the Queensland Government.TO BE COMPLETED BY APPLICANTOATHS ACT 1867 (as amended)I, make this solemn declaration by virtue of the Oaths Act 1867(as amended) that, to the best of my knowledge and belief, the information supplied on this application forCriminal Injury Compensation is true and correct in every particular. I acknowledge and make thisdeclaration in the belief that a person making a false declaration is liable to the penalties of perjury.Signature (applicant)Taken and Declared before me at this day of________________ 20 .WitnessJustice of the Peace for Queensland/SolicitorIf not in Queensland at the time of completing this form please ensure that this statutory declaration isamended and completed according to the law of the place where it is swornPrepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 6 of 8
INFORMATION SHEETCRIMINAL INJURY COMPENSATION (CIC)FOR APPLICANTS WITHOUT COURT ORDERSPrivacy StatementThe information collected for your application is collected to enable the Department of Justice & Attorney-General to process your application for an ex gratia payment of criminal injury compensation. This informationmay be disclosed to those persons necessary to verify your claim (eg. investigating Police Officers; the Officeof the Director of Public Prosecutions; Corrective Services) and to any person with a lawful entitlement toobtain the information. This information will be disclosed to departmental officers involved in processing yourclaim and to the Governor-in-Council. Failure to supply the requested information may mean that theDepartment is unable to process your claim.The following material MUST accompany all applications: Completed application form Copy of client’s authority (see over for suggested wording) Copy/ies of Medico-legal report(s) supporting ALL injuries for which compensation is sought (i.e. no awardof compensation will be made for mental/nervous shock not supported by a psychiatrist’s orpsychologist’s report).[NB – if the applicant is seeking compensation for Adverse Impacts of a Sexual Offence pursuant toRegulation 1A Criminal Offence Victims Regulation 1995, where relevant, the psychological /psychiatric report should clearly distinguish between an injury falling within the diagnosis of mental ornervous shock, and an injury falling outside that diagnosis but compensable as an adverse impact. Ifyou have any queries about this aspect of the application, please contact the Criminal InjuryCompensation Unit (07) 3239 6546.] Copy of the applicant’s statement(s) to police(This is available FREE to applicants on request to the investigating police officer)The Governor in Council DOES NOT require any of the following material: Copies of hospital inpatient records Copies of documents generated by Police Investigations Copies of witness statements (other than of an applicant’s statement)Information for ApplicantsThe department receives as many as 100 applications for criminal injury compensation per month.Although everything is done to expedite processing, it may take between 6-9 months for an applicationto be finalised because information must be obtained from other agencies (eg. the Queensland PoliceService).Ex gratia payments of criminal injury compensation may be available to a person who has suffered aninjury because of the commission of an indictable offence against them. Please note that there is nocompensation available under this scheme for loss of property, for injury or for loss suffered as a resultof the commission of an indictable offence unrelated to the person of the applicant.As a matter of policy legal costs are not included in ex gratia payments.Prepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 7 of 8
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