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VICTIMS OF CRIME ASSISTANCE RULES 2020 - REG 15

Venues of the Tribunal

Each venue of the Magistrates' Court is a venue of the Tribunal.


Form 1—Application for assistance

Rule 6

APPLICATION FOR ASSISTANCE

(Victims of Crime Assistance Rules 2020)

Victims of Crime Assistance Tribunal

Ref. No.

DETAILS OF PERSON WANTING ASSISTANCE

Surname:

Given names:

Address:     Postcode:

Telephone: (H)     (W) (M)

Occupation:

Date of birth:

Gender:

Male Female Indeterminate/Intersex/Unspecified

Email:

*Are you of Aboriginal or Torres Strait Islander origin?

person of Aboriginal or Torres Strait Islander origin means a person who is descended from an Aboriginal or Torres Strait Islander and is accepted as an Aboriginal or Torres Strait Islander by an Aboriginal or Torres Strait Islander community.

[ Persons of both Aboriginal and Torres Strait Islander origin should mark both "Yes" boxes ]

No
Yes, Aboriginal    
Yes, Torres Strait Islander    

NOTE:     This information will enable the Tribunal to provide you with information to assist your application.

Have you previously made an application for assistance or compensation under this Act?                            

Yes No

Have you previously made an application in respect of this act of violence?

Yes No

Please nominate which category applies to you—

1. Primary victim    

2. Secondary victim    

3. Related victim    

4. Application for payment of funeral expenses

PLEASE NOTE YOU CAN ONLY APPLY IN ONE CATEGORY

PLEASE COMPLETE THIS SECTION IF YOU ARE MAKING THIS CLAIM ON BEHALF OF A CHILD OR PERSON UNDER DISABILITY

Your full name:

Address:     Postcode:

Telephone:

Date of birth:

Email:

Relationship to applicant:

CIRCUMSTANCES OF THE ACT OF VIOLENCE

What was the act of violence/offence?

Where did the act of violence occur?

Date of act of violence     Time     am pm

Who committed the act of violence?

Sex of alleged offender Male Female Indeterminate/Other

*     Was the alleged offender a family member or domestic partner of the victim? Yes No

If yes, how are you related to the offender? I am the offender's

[ e.g.: wife, son, father, step-sister, former domestic partner ]    

NOTE:     This information is for data collection purposes only.

If more than 2 years have lapsed since the act of violence please outline your reasons for not filing an application within this time:

REPORTING DETAILS

Has the act of violence been reported to the Police? Yes No

If yes, please provide the officer's details:

Name:

Registered number:

Rank:

Police station:

Date of report:

If the act of violence was not reported, you must provide a statutory declaration setting out the circumstances of the act of violence and provide the reason for the failure to report the matter to police.

Have criminal proceedings commenced? Yes No Unknown

If known, provide any details known to you [ i.e. date and location of hearing ]

Are there intervention orders relating to this matter?

Yes No

Case Number (if known)

If the incident occurred in the workplace was it reported to your employer?

Yes No

Has the act of violence been reported elsewhere? Yes No

If yes, please provide details:

WHAT EFFECTS HAVE RESULTED FROM THE ACT OF VIOLENCE?

Physical     Yes No

Psychological     Yes No

Grief, distress or trauma     Yes No

Provide details:

Did you attend a public hospital? Yes No

If yes, what hospital?


DETERMINATION OF YOUR APPLICATION

Would you prefer to:
    Attend a hearing at the Tribunal? OR
Have your application determined in your absence?

Do you request that:
    Proceedings be conducted in a closed Court?
    Publication of your application be restricted?

Do you require an interpreter? Yes No If yes, specify a language.

If the Tribunal makes an award would you like it deposited into your bank account? Yes No

HAVE YOU APPLIED FOR ASSISTANCE UNDER ANY OTHER SCHEMES?



Still Pending



Finalised


Amount Received

Reference or claim number

WorkCover

$


Transport Accident Commission

$


Insurance

$


Civil Proceedings/ Sentencing

$


Other (please specify)

$


Please provide details of a claim under any of these schemes.

Please supply and attach details of any relevant insurance cover [ life or health ] or superannuation benefit entitlements held and any payments received or to be received—

by the applicant

by the deceased

TYPE OF ASSISTANCE SOUGHT

Primary victim
Special financial assistance    
Counselling
Medical expenses
Safety-related expenses
Loss of earnings
Loss of or damage to clothing
Other*

Secondary victim
Counselling
Medical expenses
Loss of earnings*
Other*

Related victim
Distress
Counselling
Medical expenses
Funeral expenses
Other*

Funeral expenses only

*Evidence of exceptional circumstances may be required.

IF DEATH WAS CAUSED BY THE ACT OF VIOLENCE

Full name of deceased:

Last known address:

Postcode:

Date of birth:

Relationship to the deceased:

Date and place of death:

NOTE: YOU MUST ALSO COMPLETE THE RELATED VICTIMS PART OF THIS FORM

THIS SECTION IS TO BE COMPLETED BY RELATED VICTIM APPLICANTS

As a related victim you are required to list—

(a)     every other person whom you believe may be a related victim; and

(b)     every other person whom you believe may allege that he or she is a related victim; and

(c)     any person whom you believe may apply because they have incurred funeral expenses as a result of the death of the primary victim.

Name of potential victim

Age of potential victim if under 18 years of age

Guardian of potential victim (if applicable)*

Address of potential victim*

Relationship of potential victim to the deceased

* If the potential victim is under 18 years of age, provide the name and address of parent, guardian or administrator.

[ Attach a separate sheet if required ]

AUTHORISATION OF APPLICANT

I     authorise the Victims of Crime Assistance Tribunal to obtain any additional evidence or documentation that the Tribunal considers necessary to enable it to determine my application.

Signature of applicant *

*Not required if application lodged online.

ACKNOWLEDGMENT

I understand and acknowledge that:

              •     To the best of my knowledge, all information provided in this application is true and correct and that no details relevant to the application have been left out.

              •     It is an offence under section 67 of the Victims of Crime Assistance Act 1996 to knowingly give false or misleading information in, or in relation to, an application for assistance.

    By ticking this checkbox I confirm that I have read and understood all the statements above.

Full name of person completing this application

Signature*

*Not required if application lodged online.

Date


Form 2—Application for review of a decision of a judicial registrar

Rule 8

APPLICATION FOR REVIEW OF A DECISION OF A JUDICIAL REGISTRAR

(Victims of Crime Assistance Rules 2020)

Victims of Crime Assistance Tribunal

DETAILS OF PERSON SEEKING REVIEW

Surname:

Given names:

Address:     Postcode:

Telephone: (H)     (W)             (M)    

DECISION TO BE REVIEWED

I apply to the Victims of Crime Assistance Tribunal under section 59A of the Victims of Crime Assistance Act 1996 to have the following decision made by a judicial registrar reviewed:

Date of decision:

Tribunal venue where decision made:

Tribunal reference No.:

NOTE:     An applicant must file an affidavit with their application setting out the reasons for seeking a review of a final decision of a judicial registrar.

MATERIAL IN SUPPORT OF REVIEW APPLICATION

Do you wish to file any additional material in support of your review application?

Yes
No

If yes, please file all additional supporting material with the Tribunal within 28 days from the date of this application.

DETERMINATION OF YOUR REVIEW APPLICATION

Would you prefer to:

    Attend a hearing at the Tribunal? OR
Have your application determined in your absence?

Do you request that:

    Proceedings be conducted in a closed Court?
    Publication of your application be restricted?

Do you require an interpreter? Yes No If yes, specify a language.

SIGNATURE OF APPLICANT

Signature:

Date:

[ signed by the person making the application
for review or the applicant's solicitor ]

NOTE:     An application for review under section 59A of the Victims of Crime Assistance Act 1996 is treated as a hearing de novo of the original application for assistance. Upon review, the Tribunal may either refuse the application for review or make its own decision in substitution for the original order.

Form 3 inserted by S.R. No. 9/2021 rule 12.

Form 3—Application for review of a decision of a Tribunal officer

Rule 8A

APPLICATION FOR REVIEW OF A DECISION OF A TRIBUNAL OFFICER

(Victims of Crime Assistance Rules 2020)

Victims of Crime Assistance Tribunal

DETAILS OF PERSON SEEKING REVIEW

Surname:

Given names:

Address:     Postcode:

Telephone: (H)     (W)     (M)    

DECISION TO BE REVIEWED

I apply to the Victims of Crime Assistance Tribunal under section 59A of the Victims of Crime Assistance Act 1996 to have the following decision made by a Tribunal officer reviewed:

Date of decision:

Tribunal venue where decision made:

Tribunal reference No.:

NOTE:     An applicant must file an affidavit with their application setting out the reasons for seeking a review of a final decision of a Tribunal officer.

MATERIAL IN SUPPORT OF REVIEW APPLICATION

Do you wish to file any additional material in support of your review application?

Yes
No

If yes, please file all additional supporting material with the Tribunal within 28 days from the date of this application.

DETERMINATION OF YOUR REVIEW APPLICATION

Would you prefer to:

    Attend a hearing at the Tribunal? OR
Have your application determined in your absence?

Do you request that:

    Proceedings be conducted in a closed Court?
    Publication of your application be restricted?

Do you require an interpreter? Yes No If yes, specify a language.

SIGNATURE OF APPLICANT

Signature:

Date:

[ signed by the person making the application
for review or the applicant's solicitor ]

NOTE:     An application for review under section 59A of the Victims of Crime Assistance Act 1996 is treated as a hearing de novo of the original application for assistance. Upon review, the Tribunal may either refuse the application for review or make its own decision in substitution for the original order.

Dated:     25 August 2020

LISA HANNAN,
Chief Magistrate

FELICITY BROUGHTON,
Deputy Chief Magistrate

SUSAN WAKELING,
Deputy Chief Magistrate

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