Approved form 2001-12

made under the
Victims of Crime (Financial Assistance) Act 1983

Victims of Crime (Financial Assistance) Act 1983–Form 1
(see s 27)

Australian Capital Territory
Victims of Crime (Financial Assistance) Act 1983
Application for financial assistance
IN THE MAGISTRATES COURT	No    of [year]
AT CANBERRA
To the Registrar:
I, [name], of [address], apply to the court for an award of financial assistance under the Victims of Crime (Financial Assistance) Act 1983.
1.  This application is made by me—
*(a)	in respect of an injury (or property damage) sustained by me;
*(b)	as a person who is responsible for the maintenance of (name) (being a person who has sustained an injury) and who has suffered pecuniary loss or incurred expense as a consequence of the injury;
*(c)	as a person who, immediately before the death of [name of deceased] (a death resulting from the injury specified below) had the following relationship with the deceased: 
*   (i)	close family member;†
*  (ii)	dependant; ‡
* (iii)	intimate personal relationship. 
2.  Date on which relevant injury (or property damage) was sustained:
3.  Particulars of the relevant injury (or property damage):
4.  Circumstances in which the relevant injury (or property damage) was sustained (including particulars in so far as they are known to me) of the action of any person as a result of which the relevant injury (or property damage) was sustained:
5.  Names and addresses of persons (if any) who are able to give evidence on my behalf in support of this application and the nature of that evidence:
6.  The action of a person as a result of which the relevant injury was sustained has (or has not) been reported to a police officer:
7.  Steps taken to enforce rights or to pursue remedies in respect of the relevant injury (or property damage):
9.  Particulars of any damages recovered by me, or compensation or other amount paid or payable to me, in respect of the relevant injury (or property damage):
10.  Particulars of any criminal proceedings, including proceedings by way of appeal instituted against a person whose action resulted in the relevant injury (or property damage) being sustained (in so far as those particulars are known to me):
11.  Copies of the following documents relevant to this application are attached:
Dated                   20      .
	.......................................…………….
	(Applicant)
*  Strike out if inapplicable
† A close family member (as defined in the Act) is a person who had a genuine personal relationship with the deceased person immediately before the person’s death, and who was at that time—
(a)	the husband or wife of the deceased; or
(b)	a parent, guardian or step-parent of the deceased; or
(c)	a child or stepchild of the deceased, or some other child of whom the deceased is the guardian; or
(d)	a brother, sister, stepbrother, stepsister, half-brother or half-sister of the deceased.
‡ 	A dependant (as defined in the Act) is—
(a)	a person wholly or partly dependent on the deceased person’s income; or
(b)	a person who would have been wholly or partly dependent on the income of the deceased person but for the incapacity of the person due to the relevant injury before his or her death; or
(c)	a child of the deceased born after his or her death who would have been a dependant by virtue of paragraph (a) or (b) if he or she had been born before the death of the deceased.

Endnotes
1	The form under the Victims of Crime (Financial Assistance) Act 1983 (the authorising Act) was originally in the schedule to that Act.  Under an amendment made by the Legislation (Consequential Amendments) Act 2001, the form became a form approved under the authorising Act, section 73 (see amdt 1.4249).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).