Information about the applicant

1. Name and surname of the applicant
(Enter the name and surname of the person submitting the request.
This person may be different from the victim.)

2. Date and place of birth of the applicant
(Enter the date and place of birth of the applicant.)

3. Identification Number
(Enter the identification number of the citizen – of the applicant.)

4. ID number or Passport number
(Enter the ID number or Passport number of the applicant.)

5. Permanent residence
(Enter the permanent residence of the applicant.)

6. Current address
(If the applicant is residing at an address different from the permanent residence address, specify the current address.)

7. Nationality
(Specify the nationality of the applicant.)

8. Telephone number
(Enter a contact telephone number for the applicant.)

9. Email address
(Enter the email address used by the applicant.)

10. Applicant is also the victim
(Specify if the applicant is also the victim by marking the appropriate answer. If the victim is another person, select "No" and proceed with filling in the victim's details.
YesNo

General Information about the Victim

11. Name and surname of the victim
(Enter the name and surname of the victim.)

12. Date and place of birth of the victim
(Enter the date and place of birth of the victim.)

13. Personal number of the citizen
(Enter the Personal Identification Number of the citizen – the victim.)

14. ID number or Passport number
(Enter the ID number or passport number of the victim.)

15. Permanent residence
(Enter the permanent residence of the victim.)

16. Current address
(If the victim is residing at an address different from the permanent residence address, specify the current address.)

17. Nationality
(Specify the nationality of the victim.)

18. Telephone
(Enter a contact telephone number for the victim.)

19. Email Address
(Enter the email address used by the victim.)

20. Name and surname of the parent/guardian of the victim
(If it is a case involving a minor victim, the name and surname of one of the parents or the name and surname of the child's guardian is indicated. )

21. Proxy of the victim
(If the victim is submitting the request through a proxy, enter the name and surname of the proxy.)

Type of victim

22. Direct victim of a crime
(A direct victim of a crime eligible to be an applicant is a person who has suffered severe physical or mental health impairment as a direct consequence of the committed violent crime or as a consequence of a violent crime in whose execution they did not participate, but the crime was committed against another person. A direct victim is also considered to be a person who has suffered severe physical or mental health impairment while trying to prevent the commission of a violent crime, while aiding the victim, and while assisting the police in apprehending the perpetrator of the violent crime.)

23. Indirect victim of a crime
(An indirect victim of a crime is a family member of a direct victim who has died as a result of a violent crime. Family members include the marital or common-law partner, child, or parent of the victim).

Data about the crime

24. Description of the Crime
(Specify the time, date, place, and method of execution of the crime. Provide a brief description of the actions constituting the crime.)

25. Name and surname of the perpetrator(s)
(If known, provide the name and surname of the perpetrator(s) of the crime for which compensation is being requested.)

Consequences of the crime

26. Description of the consequences of the crime suffered by the victim
(Provide a description of the consequences suffered by the victim as a result of the criminal act. This includes descriptions of bodily injuries, physical and mental health impairment, fear, pain, and suffering experienced by the victim.)

27. Material damage as a result of the crime
(Provide a description of the material damage suffered by the victim as a result of the crime, including damaged object, property, and other items belonging to the victim, lost earnings as result to the crime)

28. Material damage for medical treatment of the consequences from the crime
(Provide a description of the medical expenses incurred by the victim to address the consequences of the crime.)

Actions taken against the perpetrator (if the victims have this information at disposal)

29. Authority before which proceedings have been initiated against the perpetrator
(State information on where the criminal act has been reported (Ministry of Internal Affairs, Public Prosecutor's Office) and/or before which authority the proceedings against the perpetrator of the criminal offense have been initiated (Ministry of Internal Affairs, Public Prosecutor's Office, competent court)

30. Case number
(State if the case number under which the criminal offense report has been recorded and/or the case number under which proceedings against the perpetrator are being conducted before the competent authority is known)

31. Has the victim exercised the right to compensation from another source?
(State information on whether the victim has exercised the right to compensation from another source and if so, from where. Did the victim receive compensation from an insurance company, through a compensation procedure, or other means of compensation for the victim of the crime.)
YesNo

Type of compensation the victim is seeking

32. Expenses for medical treatment and medical aids (amount)
((State the amount the victim is claiming for compensation for medical treatment expenses and medical aids. The request must include proof of payment for medical treatments or the purchase of medical aids resulting from the crime.)

33. Lost earnings (amount)
(State the amount the victim is claiming for lost earnings due to the criminal act.)

34. Funeral expenses (amount)
(State the amount claimed for expenses incurred by the victim's family for the funeral. The request must include proof of payment for funeral expenses.)

35. Lost support (amount)
(State the amount claimed for lost support as result to the crime.)

36. Solidarity assistance for consequences suffered from the crime
(State the amount for solidarity assistance for the consequences suffered from the crime.)

The victim or the applicant signs a declaration confirming that they have not received compensation recognized by the Law on Payment of Monetary Compensation to Victims of Violent Crime, (*) based on other legal grounds. This declaration does not prevent the victim from exercising their right to compensation by initiating proceedings before a competent court as established by law.)

37. Declaration on non-receipt of compensation recognized by law
I, the undersigned declare that I have not received compensation recognized by the Law on Payment of Monetary Compensation to Victims of Violent Crime (*) on other legal grounds.
Therefore, I request the Commission for Compensation of Victims of Violent Crime to grant me monetary compensation.

38. List of necessary evidence enclosed to the request
Photocopies are submitted and the original or certified copy of the following documents are submitted along with the request for initiation of the compensation procedure:

• proof of citizenship, domicile or residence, except for persons pertaining to Article 8 Paragraph 3 from the Law on Payment of Monetary Compensation to Victims of Violent Crime (*),

• appropriate document from the police or from the public prosecutor's office that the crime has been registered or reported,

• proof (medical documentation) stating that the victim has suffered serious physical injuries, severe mental or physical health impairment,

• death certificate, if the victim died as a result of the crime,

• proof of incapacity for work in accordance with pension and disability insurance regulations,

• proof that the person pertaining to Article 18 Paragraph 2 from the Law on payment of monetary compensation to victims of violent crime (*) paid the funeral expenses,

• a self-signed declaration of non-receipt of compensation recognized by this law accessed on other legal grounds, (pertains to the Declaration under Item 37 of this Request, and the applicant needs to enter the date and sign),

• information on the bank account of the victim,

• other documents available to the victim, which prove that the conditions for compensation have been met in accordance with this law,

• for documents submitted in a foreign language, a certified translation in Macedonian language shall also be provided.

All evidence submitted with the request, proving the veracity of the information stated in the request, is listed.
The evidence that the victim or the claimant cannot provide should be noted in the request with an indication of where the Commission for Monetary Compensation of Victims of Violent Crimes can obtain it ex officio.
If the submitted request is incomplete, the Commission for Monetary Compensation of Victims of Violent Crimes shall invite the claimant to correct or supplement the request with the necessary evidence within 30 days from the day of receiving the notification.

NOTE:

1. Victims of violent crimes have the right to request free legal assistance for filling out the request for monetary compensation for victims of violent crimes from the regional departments of the Ministry of Justice or an association registered in the Register of Associations authorized to provide primary legal assistance according to the Law on Free Legal Aid (*).

2. Exercising the right to compensation with this request does not exclude the victim's right to claim damages or pursue other claims in accordance with another law before the competent court.

3. If during the process of exercising the right to monetary compensation according to this law, the victim exercises a right according to another law, they must notify the Commission for Monetary Compensation of Victims of Violent Crimes within seven days of exercising the right and provide proof of the exercised right and compensation.

4. The state has the right to request the return of the amount of the paid monetary compensation and the procedure costs according to this law, if the right is exercised based on false information or if the victim, or the parent or guardian, fails to notify the competent authority of facts that affect the exercise of rights in accordance with this law, or if the court determines by an effective decision that there are no elements of a criminal offense.

5. When the Commission for Monetary Compensation of Victims of Violent Crimes pays compensation to the victim or the dependent person, and they subsequently receive full or partial compensation from the perpetrator of the crime, the state has the right to claim reimbursement from the victim, the parent, or the guardian up to the amount that has been paid.

6. The Commission for Monetary Compensation of Victims of Violent Crimes will decide not to pay compensation to the victim when the procedure before the Commission for Monetary Compensation of Victims of Violent Crimes has concluded, and the payment has not been made if the compensation from the perpetrator of the crime has fully settled the damages.

By signing this request, the victim or claimant declares that they have provided accurate information and evidence and that they understand what is stated in the note. The claimant confirms by signing that they have informed the victim about the content of the note and their rights and obligations.