Form OJP-7390/5 Crime Victim Compensation State Certification Form

																							Approved OMB No: 1121-0170 Expires: XX/XX/XXXX
												U.S. Department of Justice
												Office for Victim of Crime	Office for Victims of Crime
					CRIME VICTIM COMPENSATION STATE CERTIFICATION FORM
								State of
					Reporting Period: October 1,								2012		through September 30,							2013
					NOTE: Please read the instructions on the Attached Page Before Completing this Form
	Part I: PAYMENT INFORMATION															Part II:			FUNDS AVAILABLE FOR THE STATE
																			VICTIM COMPENSATION PROGRAM
																			(During the Reporting Period)
	A:	Total Amount paid to or on behalf of crime														A:	Funds From All Sources Other Than VOCA Grant Funds
		victims from ALL FUNDING SOURCES															1.	General Funds											$	0.00
		(both State and Federal)								(+)		$	0.00				2.	Court Costs											$	0.00
																	3.	Fees											$	0.00
	B.	Amounts To Be Deducted From Total Paid															4.	Fines and Penalties											$	0.00
		to Crime Victims															5.	Private Donations											$	0.00
																	6.	Bond Forfeitures											$	0.00
		1.	Voca Grant Funds,			FY		FY				$	0.00				7.	Subrogation Recoveries											$	0.00
		2.	Subrogation Recoveries									$	0.00				8.	Restitution Recoveries											$	0.00
		3.	Restitution Recoveries									$	0.00				9.	Refunds											$	0.00
		4.	Refunds									$	0.00				10.	Reimbursements											$	0.00
		5.	Amount Awarded for Property									$	0.00				11.	Earned Interest											$	0.00
		6.	Other Reimbursements														12.	Reserves Carried Over											$	0.00
			Specify:									$	0.00				13.	Other Sources
												$	0.00						Specify:										$	0.00
																													$	0.00
	C.	Total Amount To Be Deducted
		(Sum of B1 through B6)								(-)		$	0.00			B.	Total Amount of Lines A1 through A13											(+)	$	0.00
	D.	Subtract Line C From Line A								(=)		$	0.00			C.	VOCA Grant Funds,					FY	-	FY	-			(+)	$
	E.	Recovery Costs, If Any														D.	Total Funds Received
		(Attach Documentation)								(+)		$	0.00				(Add Lines B and C)											(=)	$	0.00
	F.	Total State Payments Eligible for Matching
		VOCA Grant Award
		(Add Line D and Line E)								(=)		$	0.00
	Part III: CERTIFICATION
		I certify that the amount reported in Part I F of this form is complete and accurate.
		Type Name and Title of Duly Authorized Official
		Signature of Duly Authorized Official																								Date
	Note: This form must be signed by the authorized individual within the agency designated by the Governor to administer
			the VOCA crime victim compensation grant.
OJP Admin. Form (7390/5) (Rev. 4/99)
Paperwork Reduction Act Burden Statement: Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The estimated average time to complete the form is 1 hour. If you have comments regarding the accuracy of this estimate,
or suggestions to simplify this form, write to the Office of Victims of Crime, Office of Justice Programs, 810 7th Street, N.W., Washington, D.C. 20531. 1121-0170.