9 If the victim was injured or died because of this crime, fill out below. 10 Tell us about the victim's dependents or others who depended on the victim for support. al none, skip toil) If more than 3 dependents, attach a separate sheet and check hem 11 Did anyone besides the victim receive counseling because of this crime? (If no. skip to 12) Who received counseling, Relationship to Victim Insurance company billed for counseling Counselors name. address and phone # Who else received counseling? Policy or I0 Relationship to Victim Insurance company billed for counseling Policy or ID # Counselors name, address and phone # If more than 2 people received counseling because of this clime. check here and attach a separate sheet to describe K 12 List any insurance covering the victim or the victim's dependents. If no insurance, write "None" below If u have applied but are not covered yet, write "Pending" under Policy or ID IS. Rev September 2016 Page 3 of 4 EFTA01650819