MT-DOJ - Victim Compensation Claim Form Section A: Victim Information Victim Classification Required Primary Victim Secondary Victim Deceased Victim Primary Victim Name First Name Required Last Name Required Middle Initial Required Primary Victim Contact and Supplemental Info Date of Birth Required Sex Required Female Male Social Security Number Required Home Phone Required Work Phone Required Primary Victim Mailing Address Street or PO Box Required City Required State Required Zip Required Benefits Requested Medical Mental Health Wage Loss Death Benefits If this application is for a Secondary Victim please indicate the name of the Primary Victim and your relationship to the Primary Victim:
