Use the drop-down menu to select a role.
The Dental Treatment Form is used by dental providers to verify the care they are providing is related to the crime incident. In order to consider expenses for dental treatment, the Fund expects treatment to be reasonable, appropriate, and performed by a licensed provider.
The Employer Report Form verifies that the victim or a victim’s guardian has missed work due to crime related injury or counseling.
The Mental Health Treatment Request is used by counselors or psychiatrists to verify the care they are providing is related to the crime incident. Once completed, this form will allow for payment of up to forty sessions of a trauma-informed treatment plan.
The Virginia Victim Fund protects claimants’ information by verifying all callers. VVF staff will only discuss claims with third parties that are authorized by the claimant in this form.
The Police/Sheriff Report Form is sent to law enforcement to request information necessary to VVF eligibility determinations.
The Request for Payment Form is used by forensic nurse examiners to request payment for victim sexual assault forensic medical exams. It includes basic information about the incident, who is authorizing the forensic exam (if a physical evidence recovery kit was not provided), and itemizes the services rendered. These payments are made directly to the hospital or facility which rendered the services. Required to submit a request for payment for forensic examination-related expenses; instructions included.
The Travel and Appointment Verification Form is used to demonstrate the miles traveled to and from medical appointments related to the crime.
There is a special exception which allows for parents or guardians of child victims to claim the miles to and from court related appointments, in addition to medical appointments.
The WC4- Request for Repayment of Unclaimed Restitution is submitted by the Clerk of the Court.The repayment will be returned to that office or distributed to the victim as the WC4 directs.
The WC1 Form should be filled out by the Clerk of the Court when submitting unclaimed restitution to the Virginia Victims Fund. This form should also be submitted by the Clerk of Court by November 1 of each year if the Court is not holding any funds to be submitted as Unclaimed Restitution.
The WC2 Form is used by Clerk’s Offices to submit Unclaimed Restitution to the Virginia Victims Fund. All fields should be filled out completely and 1 check issued for the full amount of all accounts submitted. This form can also be used to submit 1 Unclaimed Restitution account separate from a quarterly or annual report.
Updated July 1, 2019
The Claim Form serves as the application to the Virginia Victims Fund. Victims indicate their interest in receiving benefits from VVF by providing this form to our office.
The Work Release allows a doctor to verify the time that a victim could not work due to crime related injury.