e-form

Application for Criminal Injuries Compensation (S.L.9.12)

Submission Date

ID Card No

Title

Name

Surname

Door Name

Door Number

Building Entry Point Name

Street Name

Locality Name

Post Code

Mobile

E-mail

Fixed Phone

In case of an applicant as a qualifying claimant:

Nature and degree of dependency on the deceased victim

Name and surname of deceased victim

Date of victim's death

Part II
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

Part III
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

Date

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.