Victims of Crime Assistance Amendment Rules 2016

Authorised by the Chief Parliamentary Counsel Authorised Version i Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 TABLE OF PROVISIONS Rule Page 1 Object 1 2 Authorising provisions 1 3 Commencement 1 4 Form 1 substituted 1 ═══════════════ Endnotes 9 -- 1 of 10 -- Authorised by the Chief Parliamentary Counsel Authorised Version 1 STATUTORY RULES 2016 S.R. No. 46/2016 Victims of Crime Assistance Act 1996 Victims of Crime Assistance Amendment Rules 2016 The Chief Magistrate together with 2 Deputy Chief Magistrates jointly make the following Rules: 1 Object The object of these Rules is to amend the Victims of Crime Assistance Rules 2010 to substitute the application for assistance set out in Form 1. 2 Authorising provisions These Rules are made under section 57 of the Victims of Crime Assistance Act 1996 and all other enabling powers. 3 Commencement These Rules come into operation on 20 May 2016. 4 Form 1 substituted For Form 1 of the Victims of Crime Assistance Rules 20101 substitute— -- 2 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 2 "FORM 1 Rule 6 APPLICATION FOR ASSISTANCE (Victims of Crime Assistance Rules 2010) Victims of Crime Assistance Tribunal Ref. No. DETAILS OF PERSON WANTING ASSISTANCE Surname Given names Address Postcode Telephone (H) (W) (M) Occupation Date of birth Sex Male  Female  Email *Are you of Aboriginal or Torres Strait Islander origin? person of Aboriginal or Torres Strait Islander origin means a person who is descended from an Aboriginal or Torres Strait Islander and is accepted as an Aboriginal or Torres Strait Islander by an Aboriginal or Torres Strait Islander community. [Persons of both Aboriginal and Torres Strait Islander origin should mark both "Yes" boxes] No  Yes, Aboriginal  Yes, Torres Strait Islander  NOTE: This information will enable the Tribunal to provide you with information to assist your application. Have you previously made an application for assistance or compensation under this Act? Yes  No  Have you previously made an application in respect of this act of violence? Yes  No  -- 3 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 3 Please nominate which category applies to you— 1. Primary victim  2. Secondary victim  3. Related victim  4. Application for payment of funeral expenses  PLEASE NOTE YOU CAN ONLY APPLY IN ONE CATEGORY PLEASE COMPLETE THIS SECTION IF YOU ARE MAKING THIS CLAIM ON BEHALF OF A CHILD OR PERSON UNDER DISABILITY Your full name Address Postcode Telephone Date of birth Email Relationship to applicant CIRCUMSTANCES OF THE ACT OF VIOLENCE What was the act of violence/offence? Where did the act of violence occur? Date of act of violence Time am  pm  Who committed the act of violence? Sex of alleged offender Male  Female  * Was the alleged offender a family member or domestic partner of the victim? Yes  No  If yes, how are you related to the offender? I am the offender's [e.g.: wife, son, father, step-sister, former domestic partner] NOTE: This information is for data collection purposes only. If more than 2 years have lapsed since the act of violence please outline your reasons for not filing an application within this time: -- 4 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 4 REPORTING DETAILS Has the act of violence been reported to the Police? Yes  No  If yes, please provide the officer's details: Name Registered number Rank Police station Date of report If the act of violence was not reported, you must provide a statutory declaration setting out the circumstances of the act of violence and provide the reason for the failure to report the matter to police. Have criminal proceedings commenced? Yes  No  Unknown  If known, provide any details known to you [i.e. date and location of hearing] Are there intervention orders relating to this matter? Yes  No  Case Number (if known) If the incident occurred in the workplace was it reported to your employer? Yes  No  Has the act of violence been reported elsewhere? Yes  No  If yes, please provide details: WHAT EFFECTS HAVE RESULTED FROM THE ACT OF VIOLENCE? Physical Yes  No  Psychological Yes  No  Grief, distress or trauma Yes  No  Provide details: Did you attend a public hospital? Yes  No  If yes, what hospital? -- 5 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 5 DETERMINATION OF YOUR APPLICATION Would you prefer to:  Attend a hearing at the Tribunal? OR  Have your application determined in your absence? Do you request that:  Proceedings be conducted in a closed Court?  Publication of your application be restricted? Do you require an interpreter? Yes  No  If yes, specify a language. If the Tribunal makes an award would you like it deposited into your bank account? Yes  No  HAVE YOU APPLIED FOR ASSISTANCE UNDER ANY OTHER SCHEMES? Still Pending Finalised Amount Received Reference or claim number  WorkCover   $  Transport Accident Commission   $  Insurance   $  Other (please specify)   $ Please provide details of a claim under any of these schemes. Please supply and attach details of any relevant insurance cover [life or health] or superannuation benefit entitlements held and any payments received or to be received— by the applicant by the deceased -- 6 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 6 TYPE OF ASSISTANCE SOUGHT Primary victim  Special financial assistance  Counselling  Medical expenses  Safety-related expenses  Loss of earnings  Loss of or damage to clothing  Other* Secondary victim  Counselling  Medical expenses  Loss of earnings*  Other* Related victim  Distress  Counselling  Medical expenses  Funeral expenses  Other*  Funeral expenses only *Evidence of exceptional circumstances may be required. IF DEATH WAS CAUSED BY THE ACT OF VIOLENCE Full name of deceased Last known address Postcode Date of birth Relationship to the deceased Date and place of death NOTE: YOU MUST ALSO COMPLETE THE RELATED VICTIMS PART OF THIS FORM -- 7 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 7 THIS SECTION IS TO BE COMPLETED BY RELATED VICTIM APPLICANTS As a related victim you are required to list— (a) every other person whom you believe may be a related victim; and (b) every other person whom you believe may allege that he or she is a related victim; and (c) any person whom you believe may apply because they have incurred funeral expenses as a result of the death of the primary victim. Name of potential victim Age of potential victim if under 18 years of age Guardian of potential victim (if applicable)* Address of potential victim* Relationship of potential victim to the deceased *If the potential victim is under 18 years of age, provide the name and address of parent, guardian or administrator. [Attach a separate sheet if required] AUTHORISATION OF APPLICANT I authorise the Victims of Crime Assistance Tribunal to obtain any additional evidence or documentation that the Tribunal considers necessary to enable it to determine my application. Signature of applicant* *Not required if application lodged online. ACKNOWLEDGMENT I understand and acknowledge that: • To the best of my knowledge, all information provided in this application is true and correct and that no details relevant to the application have been left out. • It is an offence under section 67 of the Victims of Crime Assistance Act 1996 to knowingly give false or misleading information to the Victims of Crime Assistance Tribunal. -- 8 of 10 -- Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 8  By ticking this checkbox I confirm that I have read and understood all the statements above. Full name of person completing this application Signature* *Not required if application lodged online. Date __________________". Dated: 19 May 2016 PETER LAURITSEN, Chief Magistrate LANCE MARTIN, Deputy Chief Magistrate JELENA POPOVIC, Deputy Chief Magistrate ═══════════════ -- 9 of 10 -- Endnotes Victims of Crime Assistance Amendment Rules 2016 S.R. No. 46/2016 Authorised by the Chief Parliamentary Counsel 9 Endnotes 1 Rule 4: S.R. No. 84/2010 as amended by S.R. No. 13/2014. -- 10 of 10 --