23A-28B-11. Application for compensation. An application for compensation shall be on a form prescribed by the department which sets forth:

(1) The victim's name and address, the claimant's name and address, and the relationship of the claimant to the victim;

(2) If the victim is deceased, the name and address of each dependent of the victim and the extent to which each is dependent;

(3) The date and the nature of the crime underlying the claim;

(4) The law enforcement agency or officer to whom the crime was reported and the date of the report;

(5) The nature and extent of the injuries sustained by the victim, the name and address of any person who gave medical treatment to the victim, and the name and address of any hospital where the victim received medical treatment;

(6) The total amount of economic loss that the victim, a dependent, or the claimant sustained as a result of the crime;

(7) The amount of benefits or advantages that the victim, a dependent, or other claimant has received or may be entitled to receive from any collateral source for economic loss resulting from the crime, including the name of each collateral source;

(8) Whether the claimant is a spouse, parent, child, brother or sister of the offender, or an accomplice of the offender who committed the crime;

(9) A release authorizing the department to obtain any report, document, or other information relating to the claim; and

(10) Any additional information which the department deems necessary.Source: SL 1991, ch 201, § 11; SL 1997, ch 145, § 2; SL 2002, ch 120, § 1.