Crime Victim Compensation Lost Wages Form

To submit this form, send it via email to the provided email address, fax it to 303-835-5575, or mail it to 1000 Judicial Center Drive Ste 100, Brighton, CO 80601. Ensure all required documentation is included. My advice is to double-check all entered information for accuracy before submission to avoid processing delays.

The important dates for this form in 2024 and 2025 are the deadlines for submission which may vary by case but generally within 30 days of the incident.

The purpose of the Lost Wages Form is to provide financial compensation for crime victims who are unable to work due to injury. It ensures that victims receive support for their lost income during the recovery period. Family members of deceased victims can also use the form to receive bereavement leave compensation.

• 1. Name and Title of Employee: Enter the full name and title of the employee affected by the crime.
• 2. Job/Title: Specify the job title of the employee.
• 3. Was this person employed at time of crime/injury?: Check if the employee was employed at the time of the incident.
• 4. Was this person injured at work?: Specify if the injury occurred at the workplace.
• 5. Number of hours and days missed due to crime/injury?: Enter the total number of hours and days the employee missed work.
• 6. Has this person returned to work?: Indicate if the employee has returned to work.
• 7. If yes, date of return?: Provide the date the employee returned to work, if applicable.
• 8. Was paid sick/vacation or funeral time available for this person?: Specify if the employee had available paid sick, vacation, or funeral time.
• 9. How many hours of paid sick/vacation or funeral hours has this person used due to crime/injury?: Enter the number of hours the employee used due to the incident.
• 10. How many hours of paid sick/vacation or funeral hour does this person still have available?: Specify the remaining hours available to the employee.
• 11. Prior to crime/injury: Provide details of the employee's regular and overtime hours, as well as their rate of pay.
• 12. Employer's Name: Enter the name of the employer.
• 13. Phone Number: Provide a contact phone number for the employer.
• 14. Address/City/State/Zip: Enter the employer's address including city, state, and zip code.
• 15. Supervisor/Representative Name: Specify the name of the supervisor or representative completing the form.
• 16. Title: Provide the job title of the supervisor or representative.
• 17. Employer (Supervisor/Representative) Signature: The form must be signed by the employer or their representative.
• 18. Employee (Victim/Claimant) Signature: The form must also be signed by the employee or claimant.

Failure to submit this form may result in the inability to receive compensation for lost wages due to crime-related injuries. Delayed or incomplete submissions can affect the processing time and eligibility.

• Loss of Compensation: Not submitting the form means you won't receive financial assistance for your lost wages.
• Processing Delays: Incomplete submissions may delay the processing and approval of your claim.
• Eligibility Issues: Failure to submit required documentation can result in your claim being denied.

• 1. For Crime Victims: Use this form if you are unable to work due to physical or mental injuries caused by a crime.
• 2. For Family Members: Family members of deceased victims can use this form for bereavement leave claims.
• 3. For Self-Employed Individuals: Self-employed crime victims can use this form with their tax returns as proof of income loss.
• 4. For Employers: Employers need to complete their section to provide employment and wage details for the victim.
• 5. For Healthcare Providers: Physicians or therapists must provide documentation proving the victim's inability to work.