Part A. Supporting statement
Applicant: [Name, date of birth, address, telephone, email]
Program claim number: [if assigned]
1. The event. On [date], between about [time] and [time], at [address or location, with coordinates if known], I was [taken from my bed / taken from my vehicle / approached outdoors] by [describe what was perceived, in plain terms: e.g., “figures I could not identify”] and held against my will for about [duration]. I was returned at [time] to [place]. [If there were witnesses:] [Name] saw [describe what the witness saw, e.g., “that I was missing from the house between 2:00 and 4:30 a.m.”].
2. Injuries. After the event I had [describe: puncture wounds on __; burns on __; bruising on __; nausea; loss of time; sleep disturbance; anxiety]. On [date] I was examined by [provider] at [facility], who recorded [findings]. Photographs taken on [date] are attached.
3. Report to law enforcement. On [date] at [time] I reported the event to [agency] by [in person / telephone]. [The officer took a report, number ___.] [The officer declined to take a report and said ___. I asked for a report number and was told ___.] I have answered every question asked of me by law enforcement and am willing to answer further questions.
4. Losses. Medical expenses: $[__] (bills attached). Counseling: $[__]. Lost wages: $[__] for [dates] (employer statement attached). Other: [__].
5. Collateral sources. [Health insurance; employer benefits; none.]
6. Statement. This statement describes what I perceived and the injuries that were documented. I do not know who or what was responsible. I am not making any claim against any person, and I am not asking the program to decide who was responsible.
I declare that the information in this statement is true and correct to the best of my knowledge.
[Signature] [Date]
Attachments: [medical records; photographs; police report or record of the attempt to report; witness statements; bills; wage statement]
Part B. Appeal letter
[Applicant or counsel name and address]
[Date]
[Program name] [Appeals unit or hearing office] [Address]
Re: Appeal of denial of claim no. [___], [Applicant]
Dear [Hearing Officer / Board]:
[Applicant] appeals the [date] decision denying the application. The decision states that [quote the reason]. The denial should be reversed for the following reasons.
1. The program does not require an identified or prosecuted offender. [Cite the state statute, e.g., the definition of “crime” or “criminally injurious conduct” and any provision stating that compensation may be paid whether or not the offender is identified, apprehended, prosecuted, or convicted.] Programs routinely pay claims where the offender was never identified. E.g., In re Sikute, 61 Ohio Misc. 2d 512, 580 N.E.2d 520 (Ohio Ct. Cl. 1990) (assault by unidentified assailant); In re Application of Mines, 48 Ill. Ct. Cl. 666 (1996) (injury by unknown offenders).
2. The conduct is a crime under the program’s definition. Seizing and holding a person against the person’s will and causing bodily injury are the elements of kidnapping, unlawful imprisonment, and assault under [state statutes]. [If the statute so provides:] The program pays even where the offender lacked legal capacity to commit a crime [cite; e.g., Ariz. Admin. Code R10-4-101(9)(c) (conduct that “would be punishable but the perpetrator of the conduct lacked the capacity to commit the crime”); Cal. Gov’t Code §13951(b)(1) (offense that “would constitute a misdemeanor or a felony if the crime had been committed in California by a competent adult”)]. The applicant’s inability to identify the offender does not change the nature of the conduct.
3. The applicant cooperated with law enforcement. [Applicant] reported the event on [date], within [__] hours, and answered every question asked. [If no report was taken:] The officer declined to take a report. An officer’s decision not to investigate is not a failure of cooperation by the victim, and the program’s cooperation requirement concerns the victim’s conduct. [Cite the cooperation provision.]
4. The injuries are documented. The medical records of [date] record [findings]. The program’s decision does not question the injuries or the losses.
5. Relief requested. [Applicant] asks that the denial be reversed and the claim paid in the amount of $[__], or in the alternative that the matter be set for a hearing at which [Applicant] may testify and present the treating provider’s records.
Sincerely,
[Signature]
