EFTA00129461 2. 20.111 VICTIM IDENTIFICATION FORM Date: ## CASE INFORMATION Reference Shot ID: 7 Serial # 72B-mm-111327 ## VICTIM INFORMATION

to be Returned? Yes		No	Total Loss Amount(whole dollar amount)
language
	Czech	English	French	German	Greek	Japanese
	Korean	Polish	Portuguese	Russian	Spanish	Vietnamese
	Visual	Hearing	Speech
chure	Yes	No	Contact by VWS		Yes	No
errals:	Social Services	Medical	Legal
errals:	Compensation	Support Group	Other

EFTA00129462 GUARDIAN INFORMATION (Mandatory if victim is a minor) GUARDIAN INFORMATION (Mandatory if victim is a minor) Date (First, Middle, Last) Relationship to Victim ☐ Spouse ☐ Parent ☐ Son ☐ Daughter ☐ Grandparent Grandchild ☐ Aunt ☐ Uncle ☐ Sibling ☐ Attorney ☐ Other Guardian Address City State Zip Code Country Code Home Number (Home) (Work) (Pager) NEXT OF KIN INFORMATION (Mandatory if victim is deceased) Date (First, Middle, Last) Relationship to Victim ☐ Spouse ☐ Parent ☐ Son ☐ Daughter ☐ Grandparent Grandchild ☐ Aunt ☐ Uncle ☐ Sibling ☐ Attorney ☐ Other Next of Kin Address City State Zip Code Country Code Phone Number (Home) (Work) (Pager) BUSINESS VICTIM INFORMATION Business Name Point of Contact Name (Last, First, Middle) Date of Victinization (MM/DD/YYYY) Employee Identification Number Business Account Number Address City State Zip Code Country Code Point of Contact Phone Number (Home) (Work) (Pager) Notes: