Federal Public Service Justice

FEDERAL PUBLIC SERVICE JUSTICE

/ Postal address: boulevard de Waterloo 115
1000Brussels
Offices: Rue Evers 2-8
1000 Brussels
COMMISSION FOR FINANCIAL SUPPORT
FOR THE VICTIMS OF INTENTIONAL ACTS OF VIOLENCE
AND PERSONS COMING TO THEIR ASSISTANCE / E-mail:
or

APPLICATION FOR FINANCIAL SUPPORT TO

VICTIM OF AN INTENTIONAL ACT OF VIOLENCE

(1 form per applicant, to be submitted by registered post or to the secretariat of the Commission, in duplicate)

I.CATEGORIES OF VICTIMS (must be ticked)

 Direct victim / The direct victim suffered important physical or psychological harm as the direct consequence of an intentional act of violence (box A on page 2 must also be filled in).
The guardian, provisional administrator, legal representative or parent of a minor acting on the minor's behalf must tick this category (boxes A and B on page 2 must also be filled in).
 Indirect victim, within the meaning of Article 31, 2° or 4°, of the Law of 1st August 1985 / The indirect victim aimed at Article 31, 2°, is the person entitled to inherit (within the meaning of Article 731 of the Civil Code) up to the second degree (i.e.: parents, children, brothers, sisters, grandparents, grandchildren) of a person who died following an intentional act of violence or the person who was living in a stable family relationship with the deceased (boxes A and C on page 2 must also be filled in).
The indirect victim aimed at Article 31, 4°, is the person entitled to inherit (within the meaning of Article 731 of the Civil Code) up to the second degree (i.e.: parents, children, brothers, sisters, grandparents, grandchildren) of a victim missing for more than one year or the person who was living in a stable family relationship with the deceased, when the disappearance is in all likelihood the consequence of an intentional act of violence (boxes A and C on page 2 must also be filled in).
The guardian, provisional administrator, legal representative or parent of a minor acting on the minor's behalf (who is an indirect victim within the meaning of Article 31, 2° or 4°, of the Law) must also tick this category (boxes A, B and C on page 2 must also be filled in).
 Indirect victim // Parent of a minor (within the meaning of Article 31, 3°, of the Law of 1st August 1985 / The indirect victim referred to here is the father or mother of a victim, minor at the time of the act of violence, or the person responsible for this minor when the act of violence was committed. The mother or father of a minor acting on her/his personal behalf must tick this box (boxes A and B on page 2 must also be filled in).

Box A: Applicant's personal data (this box must also be filled in by the guardian, provisional administrator, legal representative or parent of a minor acting on the minor's behalf)

Last name:………………………………………………………………………………………………..

First name: …………………………………………………………………………………………….

Address:Road: ………………………………………. No.:…………….....

Postcode: ………… Municipality: ……………………………...

Country (if outside Belgium): ……………………………………Tel.:……………………

Date and place of birth: …………………………………… ………………………….

Nationality:…………………………………………………  Mr  Mrs/Ms

Occupation (before and after the facts):………………………………………………….

E-mail: ………………………………………………………………………………………

Box B: This box must be filled in if you are applying for financial support on behalf of a minor or an incapable person: enter here the personal data of the person you are representing

Last name:………………………………………………………………………………………………..

First name: …………………………………………………………………………………………….

Address: Road: …………………………………… No.: ...... ……………......

Postcode: ………… Municipality: …………...... ……………………..

Date and place of birth: ………………………………………………………………………

Nationality:…………………………………………  Mr  Mrs/Ms

Occupation (if any): …………………………………

Relationship:……………………………………………………………………………

Reason of the representation:……………………………………………………………………………

Box C: This box must be filled in with the personal data of the deceased, the person missing or the child victim of an intentional act of violence whose parents allege damage to their own interests (Article 31, 3°, of the Law of 1st August 1985)

Last name:………………………………………………………………………………………………..

First name: …………………………………………………………………………………………….

Address: Road: …………………………………… No.:…………….....

Postcode: ……………….. Municipality: …………………………......

Country (if outside Belgium): …………………………………………………………………

Date and place of birth: …………………………………………………………………..

Nationality:…………………………………………  Mr  Mrs/Ms

Occupation: ……………………………………………………………………………

Cohabitation with the deceased or disappeared victim at the time of the facts?  No  Yes

Relationship: …....……………………………………………………………………

Date of death or date of the disappearance (for the children victims of an intentional act of violence: date of the facts): ………………………………………………………………………………………………….…

IMPORTANT!

Please fill in box D if you are represented by a lawyer before the Commission or if you are assisted by an accredited victims support centre.

Box D: This box must only be filled in if you are represented by a lawyer before the Commission or if you are assisted by a victims support centre

Name:………………………………………………Forename: ……………....

Name of centre (+ contact person): ………………...………………………………………………

Address: Road: …………………………………… No.:…………….....

Postcode: ……………… Municipality: …………………………......

Telephone: ……………………………………… Fax: …………………………………

Bar: …………………………………  Mr  Mrs/Ms

II.Facts

When did the facts occur?…………………………………………

Where did the facts occur?…………………………...... …………....

Did the facts occur in your workplace?  No  Yes …..

Brief description of the facts: …………………………...... …………..……………………………….

…………………………………...... …………....…………………...... ………….………..

…………………………...... …………..………………………………………………………….

…………………………………………………………………………………………………………...

……………………………………………………………………………………………………………

…………………………………………………………………………………………………………...

……………………………………………………………………………………………………………

…………………………………………………………………………………………………………...

……………………………………………………………………………………………………………

Identity of the perpetrator(s) if known? …………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………

III. PROCEEDINGS

Please fill in each heading of the table below.

a). Did you lodge a complaint?
 No  Yes…..If so, provide the references of the report/complaint? ……………………………………………………………………………………………………
b). Did you make a declaration of injured person?  No Yes…..
c). Did you lodge a civil-party complaint?  No Yes…..
d). Did you open a private prosecution against the perpetrator?  No Yes…..
e). Status of the judicial proceedings:
- Is the case under preliminary investigation or pre-trial investigation?  No  Yes
- If so, in which public prosecutor's office?......
f). Status of the judicial proceedings:
- Was the case closed without further action?  No Yes…..
- If so, when and on what grounds?......
g). Was the charge dismissed?  No Yes…..
- If so, when and on what grounds?......
h). Status of the judicial proceedings:
- Was a judicial decision pronounced (judgement, arrest...)?  No Yes…..
- If so, please mention the various judicial decisions pronounced in the case as well as the dates and precise if the decisions are final? …......
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………......
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….

IV. ACTION TAKEN REGARDING THE PERPETRATOR

Please fill in the table below.

a). Have you already taken action in order to get a compensation from the perpetrator?
 No  Yes …..If so, which action? …………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
b). Have you already received a reimbursement from the perpetrator?
 No  Yes … If so, how much? ……………………………………………………….

V. PRO DEO LAWYER / FREE LEGAL AID

Did you benefit from free legal aid (pro deo lawyer)?
 No  Yes
Did you benefit from free legal proceedings (exemption from paying some costs of proceedings)?
 No  Yes If so, what specific costs? .....………………………………………
( if you benefited from the intervention of an insurance covering some costs of proceedings, please fill in box VII of the form too)

VI. OCCUPATIONAL ACCIDENT / "ASSUREUR-LOI" (insurer covering occupational accidents)

Please fill in the table below.

a). Do the facts come under the legislation on occupational accidents (the facts occurred at work or on the way to work)?  No Yes…..
If so, please fill in the following boxes.
b) Particulars of the insurer and of the employer? …………………………………………………………………………………………………………..
c). Did you benefit from the intervention of the "assureur-loi"?  No Yes…..
If not, why did the "assureur-loi" not intervene? …………………………….
…………………………………………………………………………………………………………
If so, for what amount? Items of the damage taken in charge by the "assureur-loi"? …………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
d). Does the "assureur-loi" pay an annuity?  No  Yes
If so, for what (monthly or annual) amount? …………………………………………………….

VII. INTERVENTION OF AN INSURANCE

Please fill in the table below.

a). Do you have an insurance? …

personal insurance (insurance covering accidents involving bodily injury, funeral insurance, fire insurance, guaranteed income insurance, hospital insurance, death insurance):  No  Yes
legal expenses insurance (in particular for the costs of proceedings and in the framework of a potential 'insolvency of third party'):  No  Yes
civil liability insurance (civil liability family insurance, school insurance, operating insurance/operating policy, liberal professions, freelancers...):  No  Yes

If so, what type(s) of insurance? …………………………………………………………..
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..
b). Does the insurance contract contain an 'insolvency of third party' clause?  No  Yes
If so, what conditions are related to this 'insolvency of third party' clause?……………….
…………………………………………………………………………………………………..
………………………………………………………………………………………………………
c). Did you benefit from the intervention of that insurance?  No Yes…..
If not, why did the insurer not intervene? …………………………….
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
If so, for what amount? Items of the damage taken in charge by the insurance? …………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………

VIII.TYPE OF SUPPORT APPLIED FOR

Have you ever benefited from the support of the Commission (please, tick the relevant box)?

 Emergency support  Principal support

If support has already be given by the Commission, please give the references of the file before the Commission: 10/CV/RG ……………………..

Please tick the box corresponding to the type of support applied for (you may tick several items)

 Emergency support ( in most cases limited to the health care costs inasmuch as an amount of costs equal to € 500 is exposed and remains charged to the applicant) / Amount applied for (€):……………… .
between € 500 and € 15,000 or
 The applicant declares that he accepts that the amount to be granted be determined by the Commission's case law.
 Principal support ( can only be applied in the case of a final judicial decision having acquired the force of res judicata or if the case is closed without further action because the authors are unknown) / Amount applied for (€):……………… .
between € 500 and € 62,000 (minus emergency support already given) or
 The applicant declares that he accepts that the amount to be granted be determined by the Commission's case law.
 Supplementary support ( The Commission can give supplementary support during the ten years following payment of the principal support if the damage is seriously aggravated. This support can only be applied for if you have already been granted principal support) / Amount applied for (€):……………… .
€ 62,000 – principal or emergency support already granted by the Commission or
 The applicant declares that he accepts that the amount to be granted be determined by the Commission's case law.

IX. ITEMS OF THE DAMAGE APPLIED FOR

Please tick the boxes corresponding to your requests in the table below and attach the related supporting documentation.

 Administrative costs / costs of the proceedings (e.g., the expert fees, the bailiffs fees for the notification of a judgement except the legal fees which are not taken in charge by the Commission)
 Health care costs (chemist's, hospitals, psychological/psychiatric follow-up...)
 Material costs (e.g., travelling expenses...)
 Funeral expenses
 (Moral) damage related to temporary and/or permanent disabilities
 Moral damage should the victim decease
 Aesthetic damage
 Loss of income
 Loss of one or several school years
 Other? Which ones? …………………………………………………………………………………

X.Documents that MUST be attached to this form

Emergency support:

copy of the complaint (report) or proof of civil-party complaint (see III);
proof of the damage (medical files, written proofs for medical costs);
reimbursements received (mutual insurance...);
copy of legal services, family, private etc. insurance contract.

Principal support:

copy of the decision closing the case without further action (with date of and grounds for the closing) (*);
copy of the order of dismissal (*);
copy of the judgement in the criminal proceedings (*);
copy of the judgement on civil interests (*);
proof of the damage (medical files, written proofs for medical costs);
reimbursements received (mutual insurance...);
copy of legal services, family, private etc. insurance contract.
detailed report of the insurance company's intervention or official document justifying the reason for which the intervention was refused.

(*) depending on the case

supplementary support:
copy of the Commission's decision;
proof of the aggravation of the damage (medical files, written proofs for medical costs);
reimbursements received (see V).

 IMPORTANT!

If the facts come under the legislation on occupational accidents, you must give all the documents explaining in detail (with written proofs) the intervention of the "assureur-loi".

I declare on my honour that this statement is true and complete.

Date …………………………………………

Place ………………………………………

 Signature of victim/close relative or laywer (compulsory)

The request is to be handed over in duplicate to the secretary of the Commission or sent in duplicate, by registered post, at the following address:

COMMISSION FOR FINANCIAL SUPPORT

FOR THE VICTIMS OF INTENTIONAL

ACTS OF VIOLENCE

AND PERSONS COMING TO THEIR ASSISTANCE

boulevard de Waterloo, 115

1000 BRUSSELS

Tel.: (02) 542 7218 (NL)

(02) 542 7224 (NL)

(02) 542 7229 (NL)

(02) 542 7236 (NL)

(02) 542 7207 (FR)

(02) 542 7208 (FR)

(02) 542 7244 (FR)

Fax: (02) 542 7240

Regarding the persons living abroad with no lawyer in Belgium or the registered centres/services assisting the victims:
Please phone us or send us an e-mail before you submit your request!
The legal conditions to submit a request can vary from those in your own country.
+32 2 542 7236
+32 2 542 7244

or

Commission for Financial Support for the Victims of Intentional Acts of Violence and Persons coming to their Assistance - version 2015-01 p.1 of 8