Application for Criminal Injuries Compensation (S.L.9.12)
Building Entry Point Name
In case of an applicant as a qualifying claimant:
Nature and degree of dependency on the deceased victim
Name and surname of deceased victim
Information to be submitted
Place of commission of crime
Date of commission of crime
Brief description of nature and consequences of crime
Identity of assailant where known
Steps taken to inform the police, or other body or person of the circumstances giving rise to the crime
Co-operation with the police or other authority in attempting to bring the assailant to justice
If assailant has been brought to justice, state when and before which Criminal Court
Has the Criminal Court already established the compensation due to the victim/s of the crime? If so, state the date of the order
Has any legal action to claim compensation been taken? If so, state what type, when taken and, if proceedings have been terminated, the final outcome thereof
Give a sufficient description of the nature (physical, psychological, proprietary, mental damage etc.) and extent (e.g. partial or permanent disability, medical and hospitalization expenses, loss or reduction of earnings resulting from temporary or permanent inability to work) of the criminal injuries suffered, indicating the pecuniary amount of compensation hereby claimed
Certificates and documents to be attached together with this form:
1. Birth certificate of applicant.
2. Death Certificate of victim, where applicable.
3. Applicant's Police Conduct Certificate.
4. Police Report relating to the crime in question.
5. Affidavit by applicant confirming that no compensation has been awarded in connection with the crime mentioned in this application.
6. Any other documentary evidence in support of the claim hereby made, particularly medical certificates with regard to the sufficient description under Part II above.
7. Any other relevant certificates or documents.
Tick the appropriate manner in which you wish the reply to be forwarded to you
Signature of applicant
This application is to be duly filled, printed and sent with the necessary accompanying documents, to the Assisting Officer, Department of Justice, 14, 16, 18, Market Street, Floriana FRN 1082.