WTC Records Folder 0128 Disaster Information General label, 2001

NYC 9/11 Public Portal Document

NYS Crime Victims Board Personal Injury Affidavit (Complete and Attach Claim Application Page 1) Page 2 Claimant Information Claimant Name (Last) (First) (Middle) Social Security Number CVe Claim Number (If known)

Section A - Crime Information S atom Address Where Crime Occunetl (Street or PD a)(Apl, No. or FlooF) (City) (Slate) (Zip cede) Time of Crime

Alleged Perpebalpr Name (Lest) (Firs (M e) Has Alleged Perpetrator Been Arrested for the Crime? DYes DNo Has Alleged Perpetrator Been Prosecuted for this Crime?DYes DNo Is Alleged Perpetrator a member of victim's family and/or does a reside M Some household? DYes DM0 Has an order of protection been issued? (If yes, attach copy of Cr) th Dyes Duo Did the victim have essential personal property lost, damaged deslro d while attempting 10 (1) apprehend a person who committed a crime (Z) prevent a crime from Occurring (3) aim a law enforcement filter In musk an arrest? DYes DNo Is Claim being fled more than one year after be date of the Mel DYes DNo It yes, describe factors which delayed claim htinp

Section B - Injury And Medical Treatment Information Section Did victim suffer any physical injuries as a result of the crime? (l/yes cornplere questions in This section (bet apply) DYes DNo Describe injuries briefly

Fist Treaun]Nosplan Norris Address

Omer Treaap Name Adana HospMl feat Treating Dgyy Name Address (NO n Hospital) Diner 1resting poets, Name Address

F'u51 Treating Dentist Nar2 Address

rtsr Treating Name Address Ce nsebr

Section C - Medical Insurance Information Section Please fill In the name of the insurance provider and policy number or "NONE" Company Name of Primary Inaurana Pdry or ID Number

Company Name of Map Medial Potty on ID Number

Company Name at Union BmeeN (Dania( Eyewear Asschvbn) Potty o ID Number

Medicare Policy on 10 Numer

Medsaro Pdiey on ID Number

Co pany Name d N/wkere Cmipemeeon Caner Poky or ID Number

Company Name at Aulo Imuerlb Potty or ID Ninier

Convene Nears d Ober Inaurarp Patty or ID Number

Section D - Employment Information Section Was the Victim employed at me time the crime occurred? Did be Victim lose time (Tom work as a result of the Yes inlurdedescribed In Section B? Duo (if yes, complete as questions in Section DL H) Name at Donor who Ce...... d are Victinl5 DYes pNo daabtily period hood wars Nea moe Tekpwne Nwnaer Orator's Adaeas City an Tom Stare Zip Code Enipryer Name Sr Nea mole Tebprvia Numy Address City or Town State Zip code En+pbyer Name /l Area odds TeNphoe NurriM Apaess CM or Town State zip Code

[S ection E - Other Loss Information ti mnave any other rouses or eapenae5 as a result of the Crime? urtor medical fransportalpn domestic violence shelter vocational rshdlifalinl Dyes DNo amprim d by or eapenu

Section F - CIairh.Expenses Infor lion Section Do ou anllci ale that Is claim wilt exceed5,000? Yes Nu

CVBMIS 'Plot \ Rev 05115/08

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