If you are a victim of a crime and would like to be contacted by a Crime Victim Compensation specialist you may fill out an application and mail it in or enter the information below and you will be contacted. If you have any questions regarding this information call (410) 585-3010 or (888) 679-9347.
Important:  Green fields are required.

Victim and Claimant Information

Crime Victim First Name:  
Crime Victim Last Name:  
Claimant First Name:  
Claimant Last Name:  
Claimant Mailing Address:  
Claimant City:      
Claimant State:  
Claimant Zip Code:    
Claimant Gender:    
Claimant SSN:      
Claimant Date of Birth:      
(Enter as MM/DD/YYYY)
Claimant Home Phone:      
(Enter as 555 555-5555)
Claimant Work Phone:  
Claimant Other Phone:  
Claimant Email:    
List expenses you have incurred:  

Crime Information

Crime Date and Time:      
(Enter as MM/DD/YYYY hh:mm AM/PM like 03/02/2008 10:15 PM)
Description of the Crime:  
Crime Location:  

Police Department Information
Police Department  
Crime Reported Date and Time:    
  (Enter as MM/DD/YYYY hh:mm AM/PM like 03/02/2008 10:15 PM)
Police Report Number: