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Application for Crime Victim Compensation

State of CaliforniaVictim Compensation BoardForm VCGCB-VCP-005 (Rev. 10/2017) [ENG]Page 1 of 7 Application For Crime Victim CompensationAssociated Application ID(Enter if known)Section 1: ClaimantA separate Application must be filed for each person seeking 1 must be completed for all applications . The claimant is the person who has expenses or is seeking assistance as a result of a Crime . If you are filing this Application on behalf of someone else, put his/her information in Section 1 and your information in Section Spoken LanguagePreferred Written LanguageFirst NameMiddle NameLast NameGenderRelationship to VictimSocial Security Number (SSN)No SSNDate of BirthFrom the date of the Crime to now, has the claimant been in prison, on probation, on parole or post-release community supervision because of a felony?

• CalVCB will send you a letter acknowledging that your application has been received. The acknowledgment letter will include additional information about the benefits requested on your application. • A CalVCB representative may contact you for additional information if you were not able to provide it with your application.

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