Section B DETAILS OF CRIME/OFFENCE

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Section B DETAILS OF CRIME/OFFENCE

  1. 1. RETURN FORMS TO: Your Legal Representatives Or Criminal Injury Compensation Unit Department of Justice & Attorney-General GPO Box 149 BRISBANE QLD 4001 APPLICATION FOR COMPENSATION 1 (Where there is a court order) Criminal Offence Victims Act S.32 Criminal Code S.663C SECTION A DETAILS OF APPLICANT (Victim or agent to complete) Name Address Sex Male Female Date of Birth: Have you made any previous claim(s)? Yes/No Date: Reference if any: Have there been any order(s) to pay Yes/No Date: Reference if any: criminal injury compensation made against you at any stage? Are you aware of any pending Yes/No Date: Reference if any: applications for criminal injury compensation against you? SECTION B DETAILS OF CRIME/OFFENCE Date of offence Location of offence (Town or city) Brief summary of the circumstances surrounding the offence/s (this section must be completed). Please also provide a copy of your initial statement to police following the offence/s. 1 All sections are to be completed unless otherwise stated and all requested information is to be attached. Failure to do this will prevent processing of the claim. Claims are limited to the prescribed amount from time to time
  2. 2. Date of offence Prepared and relevant as at: June 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 2 of 9
  3. 3. SECTION C DETAILS OF INJURIES Brief description of injuries. SECTION D DETAILS OF CONVICTION Name of offender/s Date of conviction (please provide a certificate of conviction) Court where conviction made NB: No compensation is available for matters heard summarily in Magistrates or Children's Court (If heard on indictment in Children's Court you may be able to claim) Details of offences for which offender was actually convicted in Court Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 3 of 9
  4. 4. DETAILS OF ANY SPECIAL CIRCUMSTANCES Relationship of offender/applicant (including living in same household) Is there any possibility that offender may benefit from the claim (such as by living in same household). If so please explain how it will be ensured offender does not get benefit of compensation. Are there any other matters you believe should be taken into account in assessing this application? SECTION E COMPENSATION ORDER (please attach copy of Compensation Order) Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 4 of 9
  5. 5. SECTION F ACTION TAKEN TO ENFORCE AWARD Action taken to ascertain the ability of the Offender to pay the Court Order: eg Lands Dept search; Transport Dept search; oral examination (copies of both searches are required) Steps taken to enforce the Court Order [in full or in part]: e.g. letter of demand; warrant of execution; garnishee of wages; bankruptcy action; or other. ATTENTION - Applicants must demonstrate that the offender has been served with the Court Order and that payment in full or in part has been sought. A minimum requirement is proof of forwarding the Court Order and a letter of demand to the offender. Money received from Other Sources 1. Have any Moneys been received from: a) A civil claim in the Courts or otherwise for personal injuries; eg. any negligence action. NB: if such action can be brought this application will not be considered until the Personal Injuries Action is finalised. b) Any law relating to Workers' Compensation; NB: If the Offence(s) occurred at work (or on the way to or from work) this application for compensation will not be considered until Workers' Compensation has been finalised. c) An insurance claim; d) Any other source? 2. If moneys have not yet been received can moneys be recovered from any of the above sources? 3. Have all steps been taken to recover moneys from all of the above sources (give details of steps taken) NB That section 663E of the Criminal Code and section 38 of the Criminal Offence Victims Act 1995 provide that should you receive any payment from the offender, or become entitled, whether by an order of a court or by a compromise of action, to receive an amount of money in respect of the injury in relation to which this approval has been given, that amount is charged by way of a first charge in favour of the Attorney-General and Minister for Justice to the extent of the amount of the payment received by your client from the Queensland Government. Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 5 of 9
  6. 6. TO BE COMPLETED BY APPLICANT OATHS ACT 1867 (as amended) I, make this solemn declaration by virtue of the Oaths Act 1867 (as amended) that, to the best of my knowledge and belief, the information supplied on this application for Criminal Injury Compensation is true and correct in every particular. I acknowledge and make this declaration in the belief that a person making a false declaration is liable to the penalties of perjury. Signature (applicant) Taken and Declared before me at this day of 20 . Witness Justice of the Peace for Queensland/Solicitor If not in Queensland at the time of completing this form please ensure that this statutory declaration is amended and completed according to the law of the place where it is sworn Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 6 of 9
  7. 7. INFORMATION SHEET CRIMINAL INJURY COMPENSATION (CIC) FOR APPLICANTS WITH COURT ORDERS Privacy Statement The information collected for your application is collected to enable the Department of Justice & Attorney- General to process your application for an ex gratia payment of criminal injury compensation. This information may be disclosed to those persons necessary to verify your claim (eg. investigating Police Officers; the Office of the Director of Public Prosecutions; Corrective Services) and to any person with a lawful entitlement to obtain the information. This information will be disclosed to departmental officers involved in processing your claim and to the Governor-in-Council. Failure to supply the requested information may mean that the Department is unable to process your claim. The following material MUST accompany all applications:  Completed application form (a copy of application form is attached)  Copy of client’s authority (see over for suggested wording)  Sealed copy of court order  Reasons for judgment  Certificate of conviction  Letter of demand to offender and offender’s response (if any)  Copies of property and motor vehicle searches on offender or a statutory declaration with the results of the property and motor vehicle searches  Copy of applicant’s statement(s) to Police (This is available FREE to applicants on request to the investigating police officer) The Governor in Council DOES NOT require any of the following material:  Medical report(s)  Photographs of injuries  Court brief  Copies of documents generated by Police Investigations  Copies of witness Statements (other than the Applicant’s Statement)  The application/affidavit material for the court order Information for Applicants  The department receives as many as 100 applications for criminal injury compensation per month. Although everything is done to expedite processing, it may take 4 months or more for an application to be finalised from the date all necessary material is received.  As a matter of policy, legal costs are not included in ex gratia payments. Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 7 of 9
  8. 8.  Applicants criminally injured in the course of their employment must provide: EITHER - a letter from WorkCover (if the applicant has already applied to WorkCover) which states what amounts, if any, the applicant has received or can receive from WorkCover as a result of the injuries sustained. OR - if there is obviously no prospect of a claim to WorkCover succeeding then a medical report that makes it clear that the applicant has no permanent impairment/disability from the injuries in question and detailing the injuries that the applicant did receive as a result of the incident AND a submission from the applicant’s solicitor addressing in detail the prospects of success of the WorkCover claim.  Where an applicant is injured as a result of a criminal act and has an entitlement to pursue a civil action (for example against the applicant’s employer), the applicant or their legal advisers are required to provide advice on the applicant’s prospects of success in that action. Either a solicitor or a barrister may prepare the advice which must fully canvass the relevant legal issues.  As criminal injury compensation is an ex gratia payment payable from the public purse, where an applicant is involved in other proceedings relevant to the consideration of their application, processing of their application may be suspended until the other matter/s are finalised.  All Court Orders must be served on the offender accompanied by a letter of demand that requires the offender to list all their assets and does not refer to any entitlement to apply to the Government for criminal injury compensation.  If Queensland Transport and Queensland Land Titles searches reveal property possibly owned by the offender, advice must be provided as to whether the assets shown belong to the offender, and if so, what steps have been taken to execute against these assets.  An ex gratia payment of criminal injury compensation is made from the public purse. In making any determination, it may be possible that the payment of public monies where they could be used to acquire illegal drugs would be seen as contrary to public policy. Where there is evidence to indicate that an applicant has used or is using an illegal drug within seven years of the date of receipt of the application, the applicant will be requested to provide a pathology test result to indicate whether the applicant is currently using illegal drugs. Where an applicant chooses not to provide a pathology test result or tests positive to the presence of illegal drugs, the Governor in Council may decide that any ex gratia payment approved be forwarded to the Public Trustee to be held in trust for the applicant.  An ex gratia payment of criminal injury compensation is made from the public purse. In making any determination, it may be possible that the payment of public monies where they could be of benefit to the offender would be seen as contrary to public policy. Where there is evidence to show that an applicant continues to reside with the offender the Governor in Council may decide that any ex gratia payment approved be forwarded to the Public Trustee to be held in trust for the applicant.  If at any stage you have any questions relating to your application you should contact the Department through your legal advisers. This will ensure that the issue has not already been dealt with by your solicitors and may save you legal costs as the department’s practice is to contact an applicant’s solicitor to discuss the issues raised by the applicant.  Under the Judicial Review Act 1991 applicants are entitled to request a Statement of Reasons within 28 days of receiving notification of the decision of the Governor in Council. Applicants can also make application to the Supreme Court to seek a review of the decision of the Governor in Council.  Applicants may also make a written complaint to the Ombudsman in accordance with the provisions of the Parliamentary Commissioner Act 1974 in respect of any recommendation made to the Minister. Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 8 of 9
  9. 9.  The Government has provided Legal Aid Queensland (LAQ) with a grant to enable LAQ to assist victims of crime obtain criminal injury compensation. No means test is applied by LAQ to these victims and legal fees are capped at $4,400. LAQ can be contacted on 1300 651 188.  The Government provides funding to victims of crime groups to offer a number of counselling sessions to victims of crime. If you are in need of support or counselling the Victims of Crime Association can be contacted on 3252 2630.  Client’s Authority The client’s authority must be worded in a similar format to the following: “I [Name of Applicant] am represented by [Name of Solicitors] in relation to my criminal injury compensation application. I have discussed the particulars of my application, including the costs associated, and I hereby authorise them to act on my behalf in this matter. [Name of Solicitors] are further authorised to receive all material on my behalf with respect to my criminal injury compensation application”. Prepared and relevant as at: November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on 3239 6546 to ensure that its contents are current. Page 9 of 9

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