Nebraska Administrative Code
Topic - LAW ENFORCEMENT AND CRIMINAL JUSTICE
Title 80 - CRIME VICTIM'S REPARATIONS COMMITTEE
Chapter 2 - APPLICATION
Section 80-2-003 - Form
Current through March 20, 2024
The application form, developed by the Committee, must be fully completed and mailed with sufficient postage, submitted electronically, or delivered to the Crime Victim's Reparations program.
003.01 Incident Information - The claimant is required to provide the following, if known: a brief detailed description of the incident; the date, place, and time of the incident; the date the incident was reported to a law enforcement agency; the name of the individual who reported the incident; the name of the law enforcement agency to which the incident was reported; if the accused has been charged and/or convicted of the offense; the name or names and address(es) of any witness to the incident.
003.02 Amount of Claim - The claimant is required to enter the amount of the request by the type of services rendered as well as the total amount of the claim for compensation. Information relating to payment from other sources is required. If loss of wages is being claimed for the claimant and/or victim, the dates of work missed, the name of the victim's and/or claimant's employer, and the employer's telephone number and address are required.
003.03 Signatures - The claimant is required to sign a statement authorizing the release of information relating to the incident and to information relating to services rendered to the victim. Information and records received relating to the victim, the criminal incident and treatment shall remain confidential except for that information considered public under Nebraska or U.S. laws. The claimant is required to submit a signed statement attesting to the validity of the facts included in the claim for compensation.
