(1) The applicant seeking compensation must provide their name, residential address, date of birth and telephone number. If the applicant uses an address that is different from their residential address to receive mail, then the mailing address must also be provided.

(2) A designation on the application as to whether the applicant is a victim, a derivative victim, or a person who legally assumed the obligation to pay for a deceased victim's medical or funeral and burial expenses.

(3) If the person who signs the application as the applicant is someone other than the direct victim or derivative victim seeking assistance, the application must include some designation and supporting documentation as to the person's legal authority to apply for benefits on behalf of the victim or derivative victim (for example, a minor's parent or legal guardian, or a court appointed conservator for an adult who has been determined to be incompetent.)

(4) A description of the date, nature, location, and circumstances of the qualifying crime.

(5) Except in the case where the applicant has no pecuniary loss, a complete statement of the losses incurred and reimbursements received that are directly related to the qualifying crime. This statement must include the date or dates that medical, mental health or other professional services were provided to the victim or derivative victim, a description of the services provided affirmation that the services were in fact received, and affirmation that such services were required as a direct result of the qualifying crime and for no other reason. If mental health counseling or psychotherapy services were provided, the statement must indicate whether they occurred in an individual, family or group setting.

(6) The application must be signed under penalty of perjury by the victim, derivative victim, or other eligible applicant, attesting that the information provided in the application is true and correct to the best of their knowledge. Applications signed by an authorized representative must be signed under information and belief.

(7) A signed authorization permitting the Board staff or a joint powers victim witness center employee, or both, to verify the contents of the application.

(8) The Board may accept electronically signed applications and communications if the signature meets the following criteria:

(9) If the applicant is represented by an attorney or other authorized person, the application must include the name, address and telephone number of the representative. If the representative is an attorney, the application must include the attorney's California State Bar license number and the tax payer identification number.

(10) A statement indicating whether the victim, the victim's survivors, or the derivative victim have commenced or intend to commence a civil action to recover monetary damages from the perpetrator or perpetrators of the qualifying crime. If the applicant indicates that they have commenced or intend to commence a civil action for damages, they must include, if represented, their attorney's name, telephone number and address.

(11) A promise to contact and repay the Board if the applicant receives any payments from the offender, a civil suit, an insurance policy, or any other governmental or private agency to cover expenses that the Board has already paid.

(12) A statement disclosing all collateral benefits for which the victim, the victim's survivors, or the derivative victim have applied or for which they may be eligible. Collateral benefits include, but are not limited to, any private or public insurance or benefits, any form of public or private assistance, any salary or bereavement leave, and any restitution paid by the perpetrator(s) of the qualifying crime.

(1) If medical or mental health expenses are claimed to have been incurred as a direct result of the qualifying crime, a statement from the treating provider itemizing all expenses incurred as of the date the application was filed; and the provider's license number, business address and telephone number. A service provider who is not required to obtain a professional or occupational license but is authorized by law to offer such services as part of their ongoing business activity must provide either their social security number, or their Federal Employer Identification Number. The Board may require the submission of mental health treatment session or progress notes in order to determine whether the treatment will best aid the victim or derivative victim and is necessary as a direct result of the qualifying crime. Session notes will be kept in a confidential locked file and after review, shall be returned to the provider or destroyed by the Board upon request of the treating provider.

(2) If loss of income is claimed to have occurred as a direct result of the qualifying crime, the applicant shall produce evidence of income loss as well as a statement of disability from the treating medical or mental health provider, as described in Section 649.32 of these regulations.

(3) If funeral or burial expenses are claimed to have been incurred as a direct result of the qualifying crime, the applicant shall provide an itemized statement for all funeral or burial expenses.

(4) If rehabilitative services are claimed, the applicant shall produce evidence of that need, and documentation for rehabilitation as specified in Section 649.25 of these regulations.

1. It must be signed and dated by a law enforcement officer with personal knowledge of the investigation; and

2. It must provide sufficient, specific facts to support any findings or conclusions reached; and

3. It must include the officer's title and badge number, and the law enforcement agency's name, phone number, and address.