Virginia law states that the Virginia Victims Fund is the payer of last resort. This statute requires claimants to exhaust all available collateral resources before VVF can make payment. The resources relevant in each claim depend on both the crime type and the resources available to the victim. Advocates, victims, and Commonwealth Attorneys can use this checklist to help identify relevant insurances and resources in a case. This information will help guide the gathering of claim documentation necessary for payment.

View/Download Collateral Resource Checklist

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.

View/Download Dental Treatment Form

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

View/Download Employer Report Form

Request for Taxpayer Identification Number and Certification

View/Download Form W9

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.

View/Download Mental Health Treatment Request

The Notarized Authorization is essential to the claims process. Without a properly notarized authorization, the Virginia Victims Fund cannot begin to process a victim’s Claim Form for benefits. The Notarized Authorization allows VVF to collect documents on the victim’s behalf to help satisfy claim requirements. It also includes an acknowledgement of the terms of use, including an agreement for VVF to pay providers on the victim’s behalf, an acknowledgement that the victim will receive benefits from the fund in place of direct restitution payments from the offender, and an acknowledgement that if the victim receives benefits for expenses that VVF has paid from any other source, they must immediately repay the award. An oath that the information included in the Claim Form is correct and truthful is also included.

View/Download Notarized Authorization Form

Public information about payment of sexual assault medical forensic examinations.

View/Download Notice to Sexual Assault Patients

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.

View/Download Permission for Verbal Communications Form

The Police/Sheriff Report Form is sent to law enforcement to request information necessary to VVF eligibility determinations.

View/Download Police-Sheriff Report Form

The Prescription Voucher is used to pay for necessary medication such as the cost of the HIV post-exposure prophylactic treatment that the forensic nurse examiner or physician has recommended.

View/Download SAFE Prescription Voucher

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.

View/Download SAFE Request for Payment Form

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.

View/Download Travel and Appointment Verification Form

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.

View/Download Unclaimed Restitution and Repayment Form WC4

This form serves as the application to the Virginia Victims Fund for a victim to receive repayment of Unclaimed Restitution funds being held.

View/Download Unclaimed Restitution Application

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.

View/Download Unclaimed Restitution Report WC1

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.

View/Download Unclaimed Restitution Report WC2

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.

View/Download VVF Claim Form

The Work Release allows a doctor to verify the time that a victim could not work due to crime related injury.

View/Download Work Release Form