Applicant Information

SECTION A: APPLICANT INFORMATION

Choose one of the following (Required):

New/Revised Request for Victim Services

Change of address/phone/e-mail

Collection of court ordered restitution only/no notification services

Choose one of the following (Required):

Victim of crime(s) committed by offender

Family member of victim, Indicate Relationship:

Witness who testified against the offender

Name of Victim(s):

Please enter Victim name(s) and click the Add button.

Enter Victim Name:

Added Victim Name(s) (Required):

Person Requesting Information:

First Name (Required):

Middle Name:

Last Name (Required):

Address1:

Address1 (Required):

City (Required):

State/Other (Required):

Zip Code (Required):

Country (Required):

Address2 (Optional):

Address2:

City:

State/Other:

Zip Code:

Country:

Contact Information:

Primary Phone No. (Required):

Secondary Phone No:

E-Mail

NOTE: It is your responsibility to keep the OVSRS informed of any changes to your contact information. For additional assistance, please call 1-877-256-6877 (toll free).