Employer Report Form

Form Description

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

Form Instructions

The employer should fill out the Employer Report Form to verify the time missed by the victim or a victim’s guardian. It is essentially 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