„Příloha č. 1a k vyhlášce č. 241/2006 Sb.

Annex No. 1a to Decree No. 241/2006 Coll.

Questionnaire
for the Assessment of Applications for the Provision of Financial Support to Victims
of Criminal Acts pursuant to Act No. 209/1997 Coll., on the provision of financial support to
the victims of criminal acts and on amending certain other acts, as amended

Dear Sir/Madam,

We apologise for troubling you with personal questions in your current situation. However, filling in this questionnaire is required for the rapid assessment of your application for the provision of financial support pursuant to Act no. 209/1997. Thank you for your cooperation; it is highly appreciated.

I.	Please legibly fill in the personal data of the applicant - i.e. the victim of the criminal act who has suffered bodily harm, or the survivor of a person who has died in consequence of the criminal act:

1.	Surname:

2.	Given name:

3.	Date of birth:

4.	Permanent address:

5.	Mail delivery address (should it differ from the permanent address, only):

6.	Phone Number:

7.	E-mail address:

8.	Nationality:

II.	If the applicant is represented by another person („representative“) on the basis of statutory representation (for instance, a minor child represented by his/her parent) or on the basis of a power of attorney, please fill in the data of such representative:

1.	Surname:

2.	Given name:

3.	Permanent or registered address:

If the representative is filing the application on behalf of the applicant, please also submit a document authorizing him/her to represent the applicant - a copy of a power of attorney (for contractual representation) or a copy of the birth certificate (for statutory representation) or any other equivalent document.
III.	If the applicant is a survivor of a person who has died in consequence of the respective criminal act, please fill in the personal data of the deceased:

1.	Surname:

2.	Given name:

3.	Date of birth:

4.	Date of death:

5.	Last permanent address:

6.	Nationality:

7.	Relationship of the deceased to the applicant (e.g. father, daughter, an individual living in common household)

If the applicant is a survivor of a person who died in consequence of the criminal act, please attach a copy of the death certificate and any documents proving that the deceased supported or had an obligation to support the survivor (in the case of a parent-child relationship, such documents include birth certificates or a court decision on the obligation to support the dependent; in the case of married couples, please attach a marriage certificate).

IV.	Please specify whether you request the financial support to be sent by means of a postal payment order, or whether it shall be transferred to a bank account (in such case, please give the your bank account number).

V.	Please specify the date on which the victim learned of the consequences of the crime.

Please specify the date on which the crime was committed and, if the victim learned about the consequences of the crime at a later date, please also specify the date and the manner in which the victim learned of said consequences (e.g., the date of the medical report).

VI.	Please specify the criminal justice authority (e.g. police, public prosecutor’s office, court) which most recently conducted criminal proceedings. Enter the reference number of the file related to the respective proceedings.

If available, please attach the latest decision of the abovementioned criminal justice authority which could indicate the stage of the respective proceedings (e.g. resolution on the discontinuation of criminal prosecution, copy of the indictment, judgement - final or otherwise).

VII.	Please specify whether you have filed a claim for compensation against the offender or any other person responsible for the harm suffered. If yes, please indicate how such claim was filed.

According to the provisions of § 8 of Act no. 209/1997, the amount of financial support may be reduced or withheld depending on whether the victim has made use of all legal measures to enforce a claim for compensation against the offender or any other person responsible for the harm suffered. Do not fill in this item if the offender has not been identified.
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Fill in item VIII if the applicant is a survivor of an individual who has died in consequence of the committed crime.

VIII.	Please indicate whether you are the only person to meet the conditions given in § 2, section 2 of Act no. 209/1997, or - if these facts are known to you - how many persons meet these conditions.

1.	Are you a parent, spouse or child of the person who died in consequence of the criminal offence?

2.	Did you live in a common household with the deceased person prior to the commitment of the crime?

3.	Were you a dependent of the victim or was the deceased obliged to support you?

4.	Do any other persons meet the conditions described in numbers 1 to 3? Please give their number, if known to you.

According to the provisions of § 2, section 2 of Act no. 209/1997, a person who is a survivor of a victim who died in consequence of a criminal act is considered to be a victim if he or she is a parent, spouse or child of the deceased and lived with him or her in the same household or if the person was a dependent of the deceased or the deceased was required to support the person.

If the applicant is the victim of a crime and has suffered bodily harm, please fill in items IX -
XIV.

IX.	Please specify the date on which treatment was completed or on which the work disability came to an end.

X.	Please specify the total amount of the point-based assessment of pain and suffering:

Please attach a point-based assessment of pain and suffering pursuant to Decree No. 440/2001 Coll. The respective document should be obtained from the physician responsible for the victim’s treatment. Such medical report must contain a point-based assessment of the pain suffered and a point-based assessment of the lowering of the victim’s social position. Please bear in mind that only the point-based assessment of the pain suffered is relevant for the purposes of Act no. 209/1997. According to the provisions of § 6, section 2 of Act no. 209/1997, no financial support will be provided unless the total assessment of the pain suffered is at least 100 points.

XI.	Specify whether you are applying for lump sum payment in the amount of CZK 25,000 or whether you are submitting evidence of lost income and costs of treatment.

The victim may obtain lump sum financial support in the amount of CZK 25,000 or an amount equal to any proved costs of medical treatment and lost income (§ 7, section 1, letter a of Act No. 209/1997 Coll.). If you decide to apply for a lump sum payment, there is no need to fill in items XII - XIV.

XII.	Please specify the amount of costs related to medical treatment:

This includes any expenses for medication, sanitary equipment, rehabilitation costs, hiring an assistant to help out in the home or with medical treatment, increased transportation costs etc., provided such costs have not been paid by an insurance company. If such expenses are not proved by documentary evidence, the Ministry of Justice may not take them into consideration.

XIII.	Describe the applicant’s income prior to and after the bodily harm suffered as a result of the criminal act.

Please attach all documents confirming such facts to the application.

If the applicant is an employee, these documents shall include a statement from his/her employer describing the average salary according to § 351 et. seq. of Act no. 262/2006, the Czech Labour Code, as amended. If the applicant is self-employed, such document shall be a copy of his/her most recent tax return. If the applicant is a retired person who is able to prove his/her impaired social standing, please attach a document confirming the amount of the retirement pension. If for any reason the applicant’s income situation cannot be proven, in exceptional cases an affidavit may be attached.

XIV.	Please specify the amount of sickness benefits (disability benefits) and the period during which the applicant received or has been receiving the abovementioned benefits in connection with the bodily harm caused by the criminal act.

Please attach a statement issued by the employer or insurer confirming the amount of the sickness benefits. If the applicant has been awarded a disability pension in consequence of the bodily harm caused by the criminal act, the applicant shall prove this and specify the amount.

Affidavit of applicant for financial support pursuant to Act No. 209/1997	Coll., on the provision of financial support for the victims of criminal acts and on amending certain other acts, as amended

I hereby affirm that the information stated herein reflects actual circumstances.

My social standing has been impaired as a result of the criminal act of which I was a victim. I have not yet been compensated for the harm 1 have suffered as a result of the criminal act.

I hereby affirm that I have not lodged any claim for financial support or any similar claim for compensation for the harm suffered as a result of the criminal act in any country other than the Czech Republic.

I acknowledge that according to § 12 of Act No. 209/1997 Coll., on the provision of financial support for the victims of criminal acts and on amending certain other acts, as amended, I am obliged to reimburse the Ministry of Justice any amount received as compensation for the harm suffered, up to the amount of the financial support, within five years from the date of receiving the funding support. I also acknowledge that, after the lapse of the five-year period, I may file an application asking the Ministry of Justice to waive the state’s claim for the return of the provided support, should such a waiver be well reasoned by my social standing, the total extent of harm suffered and the amount of compensation received.
I also acknowledge that consciously giving false or incomplete information or withholding information for the purposes of unjustifiably gaining benefits may represent an offence pursuant to § 21, section 1, letter c) of Act no. 200/1990 Coll., on offences as amended.

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Signature of the applicant or his/her representative

Notice
-	Upon receipt of the application for the provision of financial support pursuant to Act No. 209/1997, the Ministry of Justice shall confirm receipt and assign it a serial number. Subsequently, the Ministry shall initiate an investigation with the police or a similar authority as per the specific details of the case. Within three months from the date of the receipt of the application and submission of the necessary documents, the Ministry shall either provide the support or inform the applicant of the reasons why such support has been withhold.

-	The applicant shall be considered a victim as per Act No. 209/1997 Coll. only if he/she has suffered bodily harm as a result of the commitment of a crime. A necessary but not the only condition for the victim’s receipt of financial support shall be the amount of the point-based assessment of the pain suffered (not the weakening of social position), which must be at least 100 points. Survivors of a victim who has died in consequence of a crime shall be considered to be a victim if the survivor is a parent, spouse or child of the deceased and the survivor shared a household with the deceased at the time of his/her death or if the deceased supported or was required to support the survivor.

-	Act No. 209/1997 Coll. on the provision of financial support to victims of criminal acts stipulates a preclusive term of 1 year from the date on which the victim learned of the harm caused by the crime. If this date does not coincide with the date of the commitment of the crime, the victim shall provide evidence of the date on which he/she learned of its consequences. The Ministry of Justice cannot meet an application for the provision of financial support received anytime after the lapse of the abovementioned period.

-	Financial support as applied for by a victim who has suffered bodily harm as a result of the commitment of a crime may be in the form of a lump sum amounting to CZK 25,000 or an amount equal to lost income or the costs of medical treatment as proved by the victim, reduced by any amount previously paid to the victim as compensation for the harm incurred. The total amount of such support must not exceed CZK 150,000. If, after the provision of support, the victim proves that the harm suffered exceeds the amount received, the victim may receive additional support up to the amount of CZK 150,000 if he/she applies for it within the abovementioned period of time (i.e., 1 year from the date on which the victim learned of the harm caused by the crime); in such case, any amounts already paid will be taken into account.

-	An individual who is a survivor of a victim who has died as a result of the commitment of a crime (a parent, spouse or child of the deceased living in a common household with the deceased at the time of his/her death or supported by or supposed to be supported by the deceased) shall be provided with a lump sum amounting to CZK 150,000. The total amount provided as financial support shall not exceed CZK 450,000; should the number of victims exceed three, the amount provided per victim shall be reduced accordingly.

-	Act No. 209/1997 Coll. does not replace the institute of the objective liability of operators of motor vehicles related to compulsory liability insurance. In matters related to traffic accidents, applications for insurance benefits should thus be directed to the insurers providing such liability insurance. Only in isolated cases, in view of exceptional circumstances, may an application for the provision of financial support be filed with the Ministry of Justice.

-	Please bear in mind that all available documents and confirmations required for the respective items must be attached to the application. If the applicant fails to do so, the Ministry of Justice cannot properly process the application. Should the applicant fail to deliver any such documents and confirmations even within a supplementary deadline, such fact may justify a decision to withhold any support as per Act No. 209/1997 Coll. This shall not, however, prejudice the filing of another application.

-	Please bear in mind that the applicant shall be obliged to return any financial amount received as compensation for harm (from the offender, insurers etc.) to the account of the Ministry of Justice up to the amount of the support received. This obligation does not apply if he/she has not received any compensation. If so requested by the victim in an application, the Ministry of Justice may waive the state’s right to claim the return of the financial support provided after the lapse of the five-year term, provided such a waiver is justified by the victim’s social standing, the total amount of the harm suffered and the amount of compensation paid to the victim.