Summary of Victims Compensation Board Claim Form

This document is a claim form utilized by the Maine Victims Compensation Board in connection with the Master Agreement for Sexual Assault Evidence Collection Kits. The form serves as the official application mechanism for victims of sexual assault seeking compensation through Maine's state victims' compensation program. The form collects comprehensive information from claimants, including personal identification details, incident information, and documentation of losses incurred as a result of the sexual assault. The form establishes the procedural framework for victims to submit claims and provides clear instructions regarding required supporting documentation, such as police reports, medical records, and evidence of expenses related to medical treatment, counseling, and other victim services.

The claim form establishes eligibility criteria and outlines the types of compensable expenses that may be covered under Maine's victims compensation program, including medical expenses, mental health treatment, lost wages, and other costs directly attributable to the sexual assault incident. The form requires claimants to provide detailed accounting of their losses and to authorize the release of relevant medical and law enforcement records to support their claims. The document functions as a critical administrative tool that bridges the sexual assault evidence collection process with the state's broader victim support and compensation infrastructure, ensuring that survivors have a clearly defined pathway to access state-funded compensation for their documented losses and expenses.