Mass Violence Fast-Track Form

State of Utah
UTAH OFFICE FOR VICTIMS OF CRIME
350 East 500 South Suite 200,

Salt Lake City, Utah 84111

(801)238-2360 or Toll Free 1-800-621-7444

Fax: (801)533-4127

Email: crimevictims@utah.gov
Mass Violence Fast-Track Form
Incident Description
Date

MonthDayYear
Victim Name*
Date of Birth*

MonthDayYear
Phone
Cell or Home
Email*
example@example.com
Mailing Address
Preferred Method of Contact
Health Insurance Provider
Identify your Location During the Violent Incident (see map)*
Complete this section if the victim is a minor, incapacitated, or deceased
Applicant Name
Relationship to Victim
Date of Birth

MonthDayYear
Phone
Cell or Home
Email
example@example.com
Address
Assignment of Recovery
I understand that pursuant to Utah Code § 63M-7-519 any money I recover from court imposed restitution; civil claim or lawsuit; insurance settlement; or other governmental or private agency shall entitle the Utah Office for Vic ms of Crime to reimbursement of any compensation awarded to me or on my behalf. I hereby assign all rights for recovery to the Utah Office for Victims of Crime including the right to initiate and enforce a claim for restitution in any court having jurisdiction within the State of Utah, regardless of whether I am made whole by any recovery. I further agree to notify the Office in writing within thirty (30) days of the date that I initiate any legal proceedings or negotiations to recover my losses.
Applicant/Victim Authorization for Release of Information
I hereby authorize the release of information to the Utah Office for Victims of Crime, including information or documents that are otherwise restricted by statute or rule, in order to evaluate my eligibility for benefits. I understand this information may be provided to law enforcement, prosecutors and medical or mental health providers in accordance with the provisions of the Governmental Records Access and Management Act.
Declaration of Truthfulness
I hereby declare that the information contained in this written statement is true and correct to the best of my knowledge and I understand that any false statements I make that I do not believe to be true may subject me to criminal punishment pursuant to Utah Code Ann. §§ 76-8-504 and 63M-7-510(2).
Date*

MonthDayYear
Victim/Applicant Signature*

Clear
Please read the above statement and if in agreement to sign and apply.
Should be Empty:

State of Utah

UTAH OFFICE FOR VICTIMS OF CRIME

Mass Violence Fast-Track Form

Complete this section if the victim is a minor, incapacitated, or deceased

Assignment of Recovery

Applicant/Victim Authorization for Release of Information

Declaration of Truthfulness