Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Application for Victim Compensation
Section 1: CalVCB Communication Preferences
Preferred Contact Method: Email Address
Preferred Spoken Language: English
Preferred Written Language: English
How did you find out about us? Victim Services Program
Section 2: My Information
Name: Kristina Denise Harvey
Mailing Address: 625 S San Pedro St, Los Angeles, California, 90014-2424, USA
Preferred Phone Number:
Additional Phone Number:
Email Address: kidkris1ne@[Link]
Date of Birth: 6/3/1984
Social Security Number: 562-81-5282
Gender: Female
Race/Ethnicity: Black/African American
From the date of the crime to now, have you been in prison, on probation, on parole or No
postrelease community supervision because of a violent felony?
Please enter your date of release (if known) from prison, probation, parole or post-release
community supervision.
Are you required to register as a sex offender? No
Section 3: Information for the person who needs help with expenses
I am paying for expenses related to the death of a loved one.
Your Relationship: Self
Name: Kristina Denise Harvey
Mailing Address: 625 S San Pedro St, Los Angeles, California, 90014-2424, USA
Date of Birth: 6/3/1984
Social Security Number: 562-81-5282
Gender: Female
Race/Ethnicity: Black/African American
From the date of the crime to now, has the claimant been in prison, on probation, on parole or No
post-release community supervision because of a violent felony?
Please enter the claimant’s date of release (if known) from prison, probation, parole or post-
release community supervision.
Is the claimant required to register as a sex offender? No
Section 4: Crime Victim Information
Relationship to Victim: They were the victim of the crime
Name: Kristina Denise Harvey
Mailing Address: 625 S San Pedro St, Los Angeles, California, 90014-2424, USA
Date of Birth: 6/3/1984
Social Security Number: 562-81-5282
Gender: Female
Race/Ethnicity: Black/African American
Was the victim disabled prior to the crime? No
Is the victim disabled due to the crime? No
Are you applying on behalf of a minor who No
witnessed a violent crime?
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 1 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Section 5: Crime Information
Was the victim involved in a Mass Casualty? No
Date of Crime: 01/30/2010 - 12/01/2023
Type of Crime: Identity Theft
Description of the crime:
I was the victim if identity Theft. For years, I have had to struggle with jobs, living situations, and filing taxes. Receivingbenefits or loans is nearly I
possible and acquiring housng is usually met with a no. I have been unable to establish myself financially for the last 10 years almost because if this. I have
also been attached to bills and some life altering events due to his. I have literally been disabled because of my inability to prove who I am. This is a
tiresome trouble which most people just shrug their shoulders at. But until it happens to you, you'll never know how dibilitating having no identity is.
Did the crime occur while the victim was on the job or at the workplace? No
Describe physical and/or emotional injuries:
It is so hard telling people why you can't open hi account or why you've been denied applications for jobs. My life has been on hold almost hi whole time
and no one knows why. It's utterly embarrassing and discouraging to tel anyone because no one understands what it's like having your identity stolen.
Victim's Date of Death (if applicable):
Location of Crime: 633 e 82nd Street, Los Angeles, California, 90003, USA, Los Angeles
Was the crime reported to Law Enforcement? No
Was the crime disclosed to another person or organization? No
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 2 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Section 6: Suspect Information
Do you know the name of the suspect(s)? No
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 3 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Section 7: Expense Information
Types of Expenses for Kristina Denise Harvey
• Mental Health Treatment
• Moving or Relocation Expenses
• Mileage or Transportation Costs
• Complementary and Alternative Treatments
Do you have immediate expenses that need to be paid? No
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 4 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Section 8: Employer Information
No Employers for this application at this time
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 5 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Section 9: Insurance(s) Information
Health Insurance Information
Does the claimant have Medi-Cal? No
Medi-Cal Benefits Identification Card Number
or SSN:
Issue Date:
Does Kristina Denise Harvey have Health Insurance? Yes
Insurance Company Name: LA Health
Policy Number:
Group Number:
Phone Number: Work (818) 321-1209
Email Address: kidkris1ne@[Link]
Mailing Address: 625 South San Pedro Street, Los Angeles, California, 90014, USA
Name of Insured: Kristina Denise Harvey
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 6 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Vehicle Insurance Information
Did the crime involve a vehicle? No
Was vehicle insurance coverage available for this crime?
Have you filed an insurance claim related to this crime?
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 7 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Workers’ Compensation Insurance Information
Have you filed a workers’ compensation insurance claim related to this crime?
Do you plan to file a workers’ compensation insurance claim related to this crime?
Insurance Company Name:
Contact Person:
Policy or Claim Number:
Phone Number:
Email Address:
Mailing Address:
Section 10: Civil Suit Information
Have you filed a civil suit related to this crime? No
Do you plan to file a civil suit related to this crime? I do not know
Do you have a civil suit attorney? No
Law Office Name:
Attorney Name:
Phone Number:
Email Address:
Mailing Address:
Section 11: Representative Information
Do you have a representative for this application? No
Type of Representative:
Victim Witness Office:
Representative Name:
Phone Number:
Email Address:
Law Office Name:
Attorney Name:
Attorney State Bar Number:
Phone Number:
Email Address:
Mailing Address:
Representative Name:
Your relationship to this person:
Phone Number:
Email Address:
Mailing Address:
Section 12: Documents Uploaded
No documents uploaded to this application at this time
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 8 of 9
Application for Kristina Denise Harvey
TEMPID-17621839 / A24-9613399
4/7/2024
Section 13: Signature
Information Release
I give permission to any healthcare provider; any medical biller, any funeral director or similar persons, any employer, any police or other government
agency, including the Department of Justice, the Social Security Administration, the State Franchise Tax Board, and the Federal Internal Revenue Service; any
insurance company; or any other person or agency, to provide information relating to this application, including medical (including, but not limited to history
or physical records, consultation reports, pathology reports, discharge summaries, operative reports, X ray and other radiology reports, laboratory reports,
chart notes, narrative reports, and billing records), mental health, and felony conviction records, to the California Victim Compensation Board (CalVCB) or its
representatives, for the purpose of determining eligibility for CalVCB benefits.
This permission also applies to all sources of recovery for the claimed losses, including but not limited to, health or medical benefits, unemployment or
disability benefits, Social Security benefits (Social Security disability, Supplemental Security income, and/or retirement, including the supporting medical and/
or mental health records), and Veteran benefits. I also give permission for the release of federal and state tax information, including tax returns, for the purpose
of verifying income.
I hereby waive all legal privileges to any of this information required by CalVCB regarding my claim.
I agree that a photocopy or fax of this signed form is as valid as the original, and my signature gives permission for the release of all specified information.
I agree that CalVCB or its representatives may pursue restitution from the convicted offender in this matter to recover monies paid to me by CalVCB and that
by filing this application I have authorized use of information in this application and subsequent claim files to pursue restitution from the convicted offender.
In order to verify or process this application, I agree that CalVCB or its representatives may provide information about this application, and the information
contained in this application, to any representative named on this application, government agency, or health care provider or other provider of services, and
may pay the provider directly if payment of these services is approved. I agree that I may revoke this authorization at any time. The revocation must be in
writing. The revocation will take effect when CalVCB receives it, but I may be deemed ineligible for CalVCB benefits once the revocation is received by
CalVCB. However, no healthcare provider may condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I am
entitled to a copy of this authorization except in limited circumstances. I agree that information disclosed under this authorization may be redisclosed by the
recipient as required by law and this redisclosure may no longer be protected by federal or state law. I agree that the authorizations and agreements herein will
expire ten (10) years after the date of my signing this form.
I have read and agree to the above “Information Release.” 04/07/2024
My Agreement to the California Victim Compensation Board
As required by California law, I will contact and repay the California Victim Compensation Board (CalVCB) if I, or anyone on my behalf, receives any payments from
the offender, a civil lawsuit, an insurance policy, or any other government or private entity, for losses suffered as a direct result of the crime that was the basis for receipt
of benefits from CalVCB, in the amount of the total benefits granted by CalVCB. I understand I may be responsible for repaying CalVCB any amount for which it is
later determined that I was not eligible.
I will notify CalVCB if I hire an attorney to represent me in any action related to this crime or if I pursue any action on my own. Any monies I receive from CalVCB
for moving/relocation expenses, improving home security, or for modifying a home or vehicle for a disabled victim will be used only for those purposes. If I am a
victim of domestic violence receiving moving/relocation expenses, I will not tell the offender my home address nor allow the offender on the premises at any time, or I
will seek a restraining order against the offender.
In the event that I am compensated for any pecuniary loss by CalVCB and the State of California subsequently receives compensation for the same loss on my behalf
from the perpetrator (including any monies received through a restitution order) or from any other source, I hereby assign to the Victim Compensation Board any and
all rights to such duplicate compensation.
I declare under penalty of perjury under the laws of the State of California that all the information I have provided is true, correct and completed to the best of my
knowledge and belief. I understand that I may be found to be ineligible for benefits, and that action may be taken to recover benefits I receive if I provide information
that is false, intentionally incomplete, or misleading.
I have read and agree to the above “My Agreement to the California Victim Compensation Board.” 04/07/2024
Signature
Please sign this application using your finger, mouse or stylus. By signing below you are declaring under penalty of perjury under the laws of the State of California
that all the information you have provided is true, correct and completed to the best of your knowledge and belief.
04/07/2024
Signature for Kristina Denise Harvey
California Victim Compensation Board
800.777.9229 | [Link] | PO Box 3036, Sacramento, CA, 95812
Hearing impaired, please call the California Relay Service (711) Page 9 of 9