Claim Form : Step 1 of 3

Claim Form Instructions

The Counseling Assistance Claim Form consists of the following:

• Preliminary Information (Step 1)
• Eligibility
  Check the box that applies to your situation. If you were abused by one of the persons identified, you are eligible to apply for counseling assistance.
• Other Requirements
  The answers to questions B 1-5 must be No for you to be eligible to apply for assistance. If you answered Yes to one of the questions, you are not eligible.
• Basic Information
  If you have met the requirements of A and B, please complete the Basic Information questions.
• Important Information (Step 2)
  Please read all of the points covered on these pages. After reading this information, it is suggested that you review the entire Claim Form (Step 3) before you begin to complete the form.
• Claim Form (Step 3)
  Please complete all of the questions on these pages.

After completing Step 3, click the Print button to print your forms. After printing your forms, sign and mail the documents to one of the Counseling Claims Administrators listed.

If you need help completing any parts of this form, please call one of the Counseling Claims Administrators.

If you would prefer to download the following forms in PDF format to print and fill out,
click here to download. Acrobat Reader needed to view PDF file format. Click here to download free Acrobat Reader.

Preliminary Information

A. Eligibility

A person who resided in Ohio, was a minor and claims that he or she was sexually abused by one of the following is eligible to apply for counseling assistance (please check the box that applies):

1.	A priest or deacon incardinated (authorized to minister as a priest or deacon) in a Catholic diocese in Ohio.
2.	A priest or deacon serving in Ohio with the permission of an Ohio Bishop.
3.	A deacon, employee, agent or volunteer authorized by an Ohio Bishop to work in a Catholic Diocese in Ohio.

B. Other Requirements

The answers to questions 1-5 below must be No for you to be eligible to apply for assistance. You are not eligible to apply for assistance if you answer Yes to any of the questions (please check the box that applies):

1.    Yes     No	I have previously reached a settlement of an abuse claim with a Bishop, Diocese or other Catholic entity.
2.    Yes     No	I have a legal action pending as to an abuse claim against a Bishop, Diocese or other Catholic entity.
3.    Yes     No	I received a determination by a court as to an abuse claim against a Bishop, Diocese or other Catholic entity.
4.    Yes     No	I have previously received counseling or financial assistance for counseling under a Diocesan Victim Assistance Program.
5.    Yes     No	I am currently receiving counseling or financial assistance for counseling through a Diocesan Victim Assistance Program.

NOTE: If you elect to file a claim with the Counseling Assistance Fund, you are not eligible to make a claim or receive assistance from a Diocesan Victim Assistance Program.

C. Basic Information

If you were abused by a person mentioned in Question A and responded No to all of the Questions in B, please complete the information below.

1.	Your Name
2.	Any other legal name
	(such as maiden name by which you were known at the time of your abuse)
3.	List the address(s) where you lived at the time of the abuse:
		a. Address #1
		Street Address
		City
		County
		b. Address #2
		Street Address
		City
		County
4.	State the name and title (if known) of the person(s) who abused you and the approximate year or years that the abuse took place (e.g., 1975, etc.):

a.	If the person who abused you was associated with a parish, please complete the following:
	Parish or Church Name
	Position or Title at Church (if known)
	City
b.	If the person who abused you was associated with a Catholic School, please complete the following:
	Catholic School name
	Position or Title at School (if known)
	City
c.	If the person who abused you was associated with a Catholic entity other than a Parish or School, please identify:
	Catholic Entity Name
	Position or Title (if known)
	City

5.

Yes      No

Did anyone report your abuse to law enforcement or children’s services?

     

Claim Form : Step 2 of 3

Important Information

• Before beginning it is recommended you read the entire Claim Form.
• If you have questions or need assistance completing this form, you may contact any of the Fund’s Counseling Claims Administrators listed on page 11.
• The Claim Form has been reviewed by mental health practitioners.
• A claim may be filed regardless of how long ago the act of abuse occurred. In order to be eligible for counseling, a claimant must file a Claim Form between November 16, 2006 and May 15, 2008.
• Any information contained in this Claim Form which has not previously been reported to law enforcement but is required under state law to be reported, will be reported.
• You will submit the Preliminary Information (Pages 2, 3 & 4) and the Claim Form (Pages 7-11) to one of the Counseling Claims Administrators listed on page 11. These persons were appointed by Probate Court Judges.
• The Counseling Claims Administrator will send the Preliminary Information (Pages 2, 3 & 4 ONLY) to the appropriate Diocesan Chancellor.
• No more than fifteen days after receiving the Preliminary Information from a Counseling Claims Administrator (Pages 2, 3 & 4 ONLY) the Diocesan Chancellor may provide information, if any, regarding the claim to the Counseling Claims Administrator.
• The Counseling Claims Administrator then submits the entire document (pages 2-11) to the independent Claims Award Panel.
• The independent Claims Award Panel decides if you will receive an award for counseling or similar mental health services and, if so, the amount of the award. The Claims Award Panel will notify you of its decision.
• The determination of the Claims Award Panel regarding your claim is final and is not subject to appeal or review by you or by any other person or entity.
• If you receive an award, you will be required to sign a waiver and release of claim(s) against the Church and others. (See the Sample Waiver on page 12)
• No payments can be made to your service provider until you sign the Waiver and Release of Claims form.
• The counseling provider you select must be licensed by an appropriate state board or agency in your state of residence.
• By submitting your claim, you are not eligible to make a claim or receive assistance under any Diocesan Victim Assistance Program.
• IF RESPONDING TO THE QUESTIONS IN THE CLAIM FORM TRIGGERS A SEVERE EMOTIONAL RESPONSE, IT IS RECOMMENDED THAT YOU CONTACT A HEALTH CARE PROVIDER IMMEDIATELY.

  

Claim Form : Step 3 of 3

PART I - PERSONAL INFORMATION

A.	Claimant's Name
B.	Date of Birth
C.	Current Address
	Street Address
	City
	Zip
	County

D.	Phone number at which you want to be contacted:
E.	If you prefer to be contacted by email please list your address here:

PART II - DETAILS OF CLAIM

A.	To the best of your recollection, please provide the approximate number of times you were abused, the time period (e.g., ten times during a period lasting less than 6 months, fifteen times during a period lasting more than 6 months, twenty-five times over a year, etc.) and your age at the time of each abuse incident.
B.	Please provide a description of the act(s) of sexual abuse and any details that preceded the actual abuse.
C.	Please provide any other information that you think the Claims Award Panel should consider in reviewing your claim.