APPLICATION FOR COMPENSATION 1 (Where there is no Court Order) Criminal Offence Victims Act S.33 Criminal Code S.663D

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1 RETURN FORMS TO: Your Legal Representatives Or Criminal Injury Compensation Unit Department of Justice & Attorney-General GPO Box 149 BRISBANE QLD 4001 APPLICATION FOR COMPENSATION 1 (Where there is no Court Order) Criminal Offence Victims Act S.33 Criminal Code S.663D SECTION A APPLICANT DETAILS (Victim or agent to complete) Name Address Sex! Male! Female Date of Birth: Have you made any previous claim(s)? Yes/No Date: Reference if any: Have there been any order(s) to pay criminal injury compensation made against you at any stage? Yes/No Date: Reference if any: Are you aware of any pending applications for criminal injury compensation against you? Yes/No Date: Reference if any: SECTION B DETAILS OF CRIME/OFFENCE Date of offence Location of offence (Town or city) Brief description of the circumstances surrounding the offence/s. 1 All sections are to be completed unless otherwise stated and all requested information is to be attached. Failure to do this will prevent processing of the claim. Claims are limited to the prescribed amount from time to time Page 1 of 8

2 Date of offence Please provide a copy of your initial statement to police following the offence/s. Claims can only be made for personal offences such as assault, wounding and rape. Claims cannot be made for property offences such as stealing unless the offender also inflicted personal injuries. SECTION C DETAILS OF INJURIES Brief description of injuries. Details of hospitalisation & medical treatment received (if any) Days in Hospital Name & Location of Hospital/Doctor Treatment SECTION D MEDICO-LEGAL REPORT(S) NB: Medical Report(s) must be attached to this application (the cost of obtaining reports is not reimbursed). Name of hospital, doctor, dentist Type of specialist (if applicable) Date of Medicolegal report Summary of report Such as torn ligament left leg, painful to walk for 6 months/unable to resume work for 3 months Page 2 of 8

3 Name of hospital, doctor, dentist Type of specialist (if applicable) Date of Medicolegal report Summary of report Such as torn ligament left leg, painful to walk for 6 months/unable to resume work for 3 months IF THE OFFENDER HAS BEEN IDENTIFIED AND THERE HAS BEEN NO CONVICTION Was there a trial on Indictment? Details of: Court Date Order (if any) NB: If the offender was convicted on indictment (Supreme or District Court) you need to get an Order against the offender and try to get the offender to pay before applying to the Government for assistance. SECTION E Was the charged person found not guilty because the person was of unsound mind? Details of: Court Date Order (if any) Was the offender unfit for Trial under the Mental Health Act? Was the offender under 10 years of age and not criminally responsible? Give details of age. SECTION F DETAILS OF INVESTIGATIONS/REPORTS Was there a personal offence, which could have been tried on indictment? Claims can only be made for personal offences such as assault, wounding and rape. Claims cannot be made for property offences such as stealing unless the offender also inflicted personal injuries. Was the offender ever identified? Was the offence reported to a Police Officer? If a sexual offence was the offence reported to a Police Officer, doctor or other agency? (eg Rape Crisis Page 3 of 8

4 Centre)? Please give details of the Police Officer, doctor or agency (and a description of the agency). NB Lack of early reporting may be a ground for refusing a claim. If there has been delay please explain the reason. Police Report It is not necessary for you to obtain a Police Report. However, if already obtained by you, attach copies of statements made to police (if any) and/or Criminal Offence Report (if any). Date incident reported to Police. (NB: The lack of early complaint to police may cause the application to be refused) Police Station reported to: Name of Investigating Police Officer(s): CURRENT location of Investigating Police Officer(s) [lack of this information may delay your application]: C.R.I.S.P. number: (this is supplied by police when matter is reported & will expedite the police report) SECTION G FURTHER PARTICULARS Was victim intoxicated? Did the victim contribute to injuries (eg falling down stairs while intoxicated) Did victim contribute in any way to the events which led to the injury (eg provoking an argument) Money received from other sources 1. Have any Moneys been received from: a) A civil claim in the Courts or otherwise for personal injuries; eg. any negligence action. NB: if such action can be brought this application will not be considered until the Personal Injuries Action is finalised. Page 4 of 8

5 b) Any law relating to Workers' Compensation; NB: If the Offence(s) occurred at work (or on the way to or from work) this application for compensation will not be considered until Workers' Compensation has been finalised. c) An insurance claim; d) Any other source? 2. If moneys have not yet been received can moneys be recovered from any of the above sources? 3. Have all steps been taken to recover moneys from all of the above sources (give details of steps taken) Details of any special or extraordinary circumstances you believe should be considered Relationship of offender/applicant (including living in same household) Is there any possibility that offender may benefit from the claim (such as by living in same household). If so please explain how it will be ensured offender does not get benefit of compensation. Are there any other matters you believe should be taken into account in assessing this application SECTION H TO BE COMPLETED ONLY IF INJURED HELPING A POLICE OFFICER Was the victim helping a Police Officer? Name & number of the Police Officer Was the Police Officer: i) Trying to arrest someone (give details); ii) Preventing or attempting to prevent an offence or suspected offence (give details) Page 5 of 8

6 TO BE COMPLETED IF IDENTITY OF OFFENDER UNKNOWN AT TIME OF APPLICATION I agree that if at any future time I become aware of the identity or whereabouts of the person responsible for my injuries, I will notify the Director-General, Department of Justice and Attorney-General immediately. Signed (please print full name) Witnessed (please print full name) Dated the.day of.20. NB That section 663E of the Criminal Code and section 38 of the Criminal Offence Victims Act 1995 provide that should you receive any payment from the offender, or become entitled, whether by an order of a court or by a compromise of action, to receive an amount of money in respect of the injury in relation to which this approval has been given, that amount is charged by way of a first charge in favour of the Attorney-General and Minister for Justice to the extent of the amount of the payment received by your client from the Queensland Government. TO BE COMPLETED BY APPLICANT OATHS ACT 1867 (as amended) I, make this solemn declaration by virtue of the Oaths Act 1867 (as amended) that, to the best of my knowledge and belief, the information supplied on this application for Criminal Injury Compensation is true and correct in every particular. I acknowledge and make this declaration in the belief that a person making a false declaration is liable to the penalties of perjury. Signature (applicant) Taken and Declared before me at this day of 20. Witness Justice of the Peace for Queensland/Solicitor If not in Queensland at the time of completing this form please ensure that this statutory declaration is amended and completed according to the law of the place where it is sworn Page 6 of 8

7 INFORMATION SHEET CRIMINAL INJURY COMPENSATION (CIC) FOR APPLICANTS WITHOUT COURT ORDERS Privacy Statement The information collected for your application is collected to enable the Department of Justice & Attorney- General to process your application for an ex gratia payment of criminal injury compensation. This information may be disclosed to those persons necessary to verify your claim (eg. investigating Police Officers; the Office of the Director of Public Prosecutions; Corrective Services) and to any person with a lawful entitlement to obtain the information. This information will be disclosed to departmental officers involved in processing your claim and to the Governor-in-Council. Failure to supply the requested information may mean that the Department is unable to process your claim. The following material MUST accompany all applications:! Completed application form! Copy of client s authority (see over for suggested wording)! Copy/ies of Medico-legal report(s) supporting ALL injuries for which compensation is sought (i.e. no award of compensation will be made for mental/nervous shock not supported by a psychiatrist s or psychologist s report). [NB if the applicant is seeking compensation for Adverse Impacts of a Sexual Offence pursuant to Regulation 1A Criminal Offence Victims Regulation 1995, where relevant, the psychological / psychiatric report should clearly distinguish between an injury falling within the diagnosis of mental or nervous shock, and an injury falling outside that diagnosis but compensable as an adverse impact. If you have any queries about this aspect of the application, please contact the Criminal Injury Compensation Unit (07) ]! Copy of the applicant s statement(s) to police (This is available FREE to applicants on request to the investigating police officer) The Governor in Council DOES NOT require any of the following material: " Copies of hospital inpatient records " Copies of documents generated by Police Investigations " Copies of witness statements (other than of an applicant s statement) Information for Applicants # The department receives as many as 100 applications for criminal injury compensation per month. Although everything is done to expedite processing, it may take between 6-9 months for an application to be finalised because information must be obtained from other agencies (eg. the Queensland Police Service). # Ex gratia payments of criminal injury compensation may be available to a person who has suffered an injury because of the commission of an indictable offence against them. Please note that there is no compensation available under this scheme for loss of property, for injury or for loss suffered as a result of the commission of an indictable offence unrelated to the person of the applicant. # As a matter of policy legal costs are not included in ex gratia payments. Page 7 of 8

8 # All applicants criminally injured in the course of their employment must provide a letter from WorkCover that states what amounts, if any, the applicant has received or can receive from WorkCover as a result of the injuries sustained. # Where an applicant injured as a result of a criminal act has an entitlement to pursue a civil action in relation to these injuries, the applicant or their legal advisers are required to provide an advice on the applicant s prospects of success in that action. Either a solicitor or a barrister may prepare the advice which must fully canvass the relevant legal issues. # As criminal injury compensation is an ex gratia payment payable from the public purse, where an applicant is involved in other proceedings relevant to the consideration of their application, processing of their application may be suspended until the other matter/s are finalised. # An ex gratia payment of criminal injury compensation is made from the public purse. In making any determination, it may be possible that the payment of public monies where they could be used to acquire illegal drugs would be seen as contrary to public policy. Where there is evidence to indicate that an applicant has used or is using an illegal drug within seven years of the date of receipt of the application, the applicant will be requested to provide a pathology test result to indicate whether the applicant is currently using illegal drugs. Where an applicant chooses not to provide a pathology test result or tests positive to the presence of illegal drugs, the Governor in Council may decide that any ex gratia payment approved be forwarded to the Public Trustee to be held in trust for the applicant. # An ex gratia payment of criminal injury compensation is made from the public purse. In making any determination, it may be possible that the payment of public monies where they could be of benefit to the offender would be seen as contrary to public policy. Where there is evidence to show that an applicant continues to reside with the offender the Governor in Council may decide that any ex gratia payment approved be forwarded to the Public Trustee to be held in trust for the applicant. # If at any stage you have any questions relating to your application, you should contact the Department through your legal advisers. This will ensure that the issue has not already been dealt with by your solicitors and may save you legal costs as the department s practice is to contact an applicant s solicitor to discuss the issues raised by the applicant. # Under the Judicial Review Act 1991 applicants are entitled to request a Statement of Reasons within 28 days of receiving notification of the Governor in Council s decision. Applicants can also make application to the Supreme Court to seek a review of the decision. # Applicants may also make a written complaint to the Ombudsman in accordance with the provisions of the Parliamentary Commissioner Act 1974 in respect of any recommendation made to the Minister. # The Government has provided Legal Aid Queensland (LAQ) with a grant to enable LAQ to assist victims of crime obtain criminal injury compensation. No means test is applied by LAQ to these victims and legal fees are capped at $4,400. LAQ can be contacted on # The Government provides funding to victims of crime groups to offer a number of counselling sessions to victims of crime. If you are in need of support or counselling the Victims of Crime Association can be contacted on Client s Authority The client s authority must be worded in a similar format to the following: I [Name of Applicant] am represented by [Name of Solicitors] in relation to my criminal injury compensation application. I have discussed the particulars of my application, including the costs associated, and I hereby authorise them to act on my behalf in this matter. [Name of Solicitors] are further authorised to receive all material on my behalf with respect to my criminal injury compensation application. Page 8 of 8