Employer Report Form

Download Employer Report Form

The Employer Report Form verifies that the victim or a victim’s guardian has missed work due to crime related injury or counseling.

Claimants should give employers this form to fill out. How and when claimants share this form is a personal decision that claimants control.

An optional cover letter is also provided for claimants to use.

The employer should fill out the Employer Report Form to verify the time missed by the victim or a victim’s guardian. It is essential that this form be completed in its entirety, including all sections about paid time off. VVF can only cover lost wages for time not compensated using paid leave. The Employer Report Form should be signed by a notary public before being submitted to the Virginia Victims Fund.

Fax or mail to:
Virginia Victims Fund
P.O. Box 26927
Richmond, VA 23261
Fax: 804-823-6905