WTC Records Folder 0128 Disaster Information General label, 2001

NYC 9/11 Public Portal Document

NYS Crime Victims Board Claim Appliidation r 'ç' J. cow urc msuucuons caremny before you complete the application ID;!y_tf!i ,t. :. .Claim Number Please print. Incomplete or inaccurate information will delay processing Crime Victim Section complete all;q e56oris ';' R,rlai ,pp Last Name iF I` First Name Mi Social Security Number Dote of Binh / / Apartment number Address Number or PO Bin Street

City or Town NYS County of Residence or Foreign Country Stale Zip Code

'Check the boxes that apply to the prileb Vlctlm'j_bnt.T .pi ylFiil=:"~ •[t'. Gender Race/Ethnicity (collected for statisticaf purposes only) Olaablad V. BID OMah OWTie (W) oBlacx (0) oAslaNPecigc Islander (A) OHlapenlc (HI [] Yes ONO Female OAnurlcan IndiarAlaskan Native I) pOther (0) Unknown (U) purrknown now did you llrst hear about the crime V e Compensation Program? Marital Stalin [] Polka (P) spiral (H) pDi torney (0) r (R) [] Single OManled ODlvorced [] Separate VI alstance Pr rem pBrocbur era (B) pOti.er (0) lJdowed pUvh,g Together

';Claimant Section (complete only i(,somebhe different than,Crirne.Victiii-is filing, this claim) -; Last Name First Name MI Social Security Number Data of Birth / / Apartment number Address Number or PO Box Sheet

Clly or Town NYS County of Residence or Foreign Country Stale Zip Code

What is your relationship to the victim? (Check only one box) Parent P 5 puss 5) flCliild (C) Relellva R Allorne (A) OOuardien 0 Other (O)

'Crime -Section (complete all questions ,I, a I ' lv ! t /, Which of the following was the result of the crime? (check all that apply) Personal Injury Death gLoss of property Date or Crime Police agency or precinct w r crlm was reported Police c anlgr rm st number

Dale rePo /lop County where. crime occurred Name of alleged perpebalor n)

Baal desolation of crime

Please Indicate the type of crime (check one box) [] Assault (1) OHomlclde (2) [] Sexual Aaseult (3) cjçhlldorSexual Wild (4 oChlid Physical Abuse (5) OChlld oDomesticVloloncof Domestic Violence (6) [] ODAI/DUI DWI/DUI (7) Crime Location (check only one) Downed Residence [] Apartment Bldg [] Public Street [] Subway/Bus [] Place of Work OSchooVSchool grounds oRestauranuBar OShopping Mail [] Parking Lot [] Other (please note In crime deecrlpllon) DidN,e victim have property lost..dameged or destroyed as a result of the above crime? ' ONo :- H' I DYes - II it es, complete below regarding loss due (o the above crime and Insurance coverage; Property Ibis award maximum $100.00 Item description Cost Homeowner! Renter Ins Company Policy Number I Deductible

- Auto / Other Insurance Company Policy Number /Deductible

Iln-behalrof.Claimant Sectlon.(Dealli;blunt onl"I if,filing for.fiilnor or Lan Name ico(npetent'dependent of victim): . 1First Name MI Social Security Number Date of Birth

'Altorney. Section (complete onl if atlorne'ietalned) -ja I, .M '"r , lw(r; Attorney or Lew Office Name prey code Telephone Number Adtlreae Number Street or PO Box Cfiy or Town Slate Zip rode

I ACKNOWLEDGE that accepting an award from the Crime Victims Board Creole, a lien in favor of the Slate of New York on any recovery from with liability relating to the Crime upon which this Claim Is based. anyone Such lien shat intend to any proceeds recovered by me by way o/ selllamenl, reanlutlon. or otherwise, and will equal the total of all )udgmenl, awards. I understand that I will retain a fight of action to recover damages for the amount of my loss lees the amount of any award I might receive. fut

I AGREE that the Attorney General of the State may intervene M any such action on behalf of the State for the purpose of racovering the total of Board awards, and that I may late In any action brought by amount the Attorney General. I agree to sign and deliver ell document, necessary to further any cause of action so assigned to the and do all things State. I also agree that I wig sign no release In settlement of any lawsuit crime without the express written consent of the Board. related to the

Notice: Filing a false claim Is a crime. Claim Application must be signed and dated. i Clalnianl's - SI nature -d'"I; I S.1-'.."3 (: 4''I4's.: Dale '. d;v Daytime area code/telephone

••., ~, Rev ('7/19197

NYC-WTC 000137346