1-40-107. Application for compensation; required information.

(a) The application for compensation shall be on a form furnished by the division, setting forth:

(i) The victim's name and address;

(ii) If the victim is deceased, the claimant's name and address and his relationship to the victim, the names and addresses of the victim's dependents and the extent to which each is dependent;

(iii) The date and nature of the criminal act on which claim for compensation is based;

(iv) The date and place where and the law enforcement officials to whom notification of the criminal act was given;

(v) The nature and extent of the injuries the victim sustained and the names and addresses of those giving medical and hospitalization treatment to the victim;

(vi) The economic loss to the applicant and to all other persons as specified under paragraph (a)(ii) of this section resulting from the injury or death;

(vii) The amount and source of benefits, payments or awards, if any, payable to the applicant and dependents;

(viii) Releases authorizing the surrender to the division of all reports, medical records and other information relating to the claim and crime; and

(ix) Any other information the division reasonably requires.

(b) The division may require that materials substantiating the facts stated in the application be submitted with the application. If the division finds that an application does not contain the required information or that the facts stated therein have not been substantiated, it shall notify the applicant in writing of the specific additional items or information or materials required and that the applicant has thirty (30) days from the date of the notice in which to furnish those items to the division. The division shall reject the application of an applicant who although notified fails to file the requested information or substantiating materials within the time specified unless he requests, and the division grants, an extension of time in which to furnish that information.

(c) An applicant may file an amended application or additional substantiating materials to correct inadvertent errors or omissions at any time before the division disposes of the original application. In either case, the filing of additional information or of an amended application shall be considered to have been filed at the same time as the original application.

(d) Information contained in the claim files and records of victims, which are subject to any privilege of confidentiality under Wyoming law, shall remain confidential and shall not be open to public inspection. The information shall be immune from legal process and shall not, without the consent of the person furnishing the information, be admitted as evidence or used for any purpose in any action, suit or other judicial, legislative or administrative proceeding.