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Application - Minnesota

Instructions Eligibility Requirements If you need help completing this Application form, contact our office or your local victim assistance program. Visit our website for a listing of victim assistance programs. Please read the following before completing the form: Print clearly and provide as much information aspossible. Submit Application as soon as possible. Additionalbills/documents can be sent later. Complete a separate Application form for eachvictim. A parent, guardian or relative must file theapplication on behalf of a minor, incapacitated ordeceased victim. Include copies of all expenses (medical bills,receipts, insurance statements), if available. Complete the W9 form (page 5) for the person whomay receive a direct payment. Sign and date the release form (page 6). The timeperiod in Section 15 should cover from the crimedate through the last expected treatment date.

The purpose of this form is to obtain or confirm your correct taxpayer name and identification number. Federal and state tax regulations require that we have this information from recipients of certain payments in order to report such payments to the Internal Revenue Service on the Form 1099 Return. Please complete items 1, 2, and 3 below.

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