9 If the victim was injured or died because of this crime, fill out below. Describe the victims injuries. briefly NN X QLiCIC Act chl`-.), cu_c__Y r. CE it t eV170.-3, Did the victim receive any medical treatment? 0 Yes J (If No, skip to Tell us about the health professionals who treated the victim for injuries related First Hospital Other Hospital First Doctor (riot on hospta0 Other Doctor First Dentist Victim s Counselor Full Name Complete Address rnfvtc f.-r(1-‘c sectfon10.)77t* ge-c- A0V-n+ VI S EACri to this crime: Phone X 10 Tell us about the victim's dependents or o depended on the victim for support. (II none, skip to 11 ) Social Secunty atin • - _ • __ Rnl nt Dependent hIn In Victim Are you the legal guardian? 0 Yes 0 No Other Relationship to Victim Dependent Other Dependent 11 Name Address Name Social Secunty • _ _ • Social Security — — Date of Binh Date of Birth Address if more Than 3 dependents. attach a separate sheet and check hew 0 Did anyone besides the victim receive counseling because of this crime? (If no. skip to 12 ) Who received counseling? Relationship to Victim Counselor's name. address and phone # Who else received counseling? Relationship to Victim Counselor's name, address and phone # Are you the legal guardian? 0 Yes 0 No Relationship to Victim Are you the legal guardian? 0 Yes 0 No Insurance company billed for counseling Insurance company billed for counseling Policy or ID It Policy or ID # If more than 2 people received counseling because of this crime, check here and attach a separate sheet to descnbe 0 12 List any insurance covering the victim or the victim's dependents. If no insurance. write "None" below If you have applied but are not covered yet. write 'Pending' under Policy or ID #. Poen or ID # Alamo ofarson's, myerefl by this incritiner Pnmary Insurance Company Major Medical Insurance Company Other Insurance (Union, Deed& Vision at) Medicare Medicaid Wo