WTC Records Folder 0128 Disaster Information General label, 2001

NYC 9/11 Public Portal Document ; Section G - Victim Assistance information Did a Victim Assiatance Program help you to complete this affidavil? | Name of Program fives [No Name of Person who helped you VAP. CVBID Areacoda Telephone Number Section H - Employment Insurance And Benefit Information Section fs there Insurance thal will Pay for the victim's lost lima fom work? (if yes, complete questions in this section) O Yes (No Unemptoyment insurance ID Numbet or “NONE™ \ / Socia! Security /SS11D Number Or “Note” Company Name of Worker's Compensation Carvar \ / Policy or ID Number Company Nema of Disability Insurance Policy of ID Number Company Name of Pension Plan / a or ID Number Company Name of Other Insurance / Policy or ID Number Section | - Dependents of Victim information Section Are there Children or other individuals who are dependent on the Victim for their support? fityes, complete ef that apply) T]¥es _[JNo Dependent Name (Last) {Firat} | Date of Bhth (MM/DDAYYY) Relationship to Viciim Address City of Town State 2p Code Dependent Name (Lasi) ~ (Firat) Date of Birth (MMDDATYYY} ry ip to Vien Address City of Town State Zip Code Dependent Name (Last (Firat) Date of Binh (MM/DDATYYY) Relationship to Victim - Address. City of Town State Zip Code Dependent Name (Last) (Firat) | Date of Girth MMDDAYYYY) Relationship to Victim Address City of Town State 2p Code Claimant Information - Please Print Claimant Name (Last) {First } (Middte) CVB Claim Number (if known) Authorization | HEREBY AUTHORIZE any hospital, physician, or olher Person who altended or examines; any undertaker OF person who renders services; any employers of the victim: any police or any municipal authority or slale department or agency, or public authority; any insurance company or organization; or any other person, firm, agency or organization having knowledge thereof, to furnish the New York Stale Crime Viclims Board, or ils representalives, any and all information, including Worker's Compensation records, wilh respect to the incident ieading to the victim's Personal injuries or death, and the claim made herewith for benefits, 1 HEREBY AUTHORIZE AND DIRECT that if an award is made, thal oul-of-pocket expenses including indebtedness reasonably incurred for medical, of other expenses necessary as @ resull of the injury, upon which the claim is based, and unpaid at the time (he decision is made and also atlorney’s fees as allowed by the Board shail be paid by Ihe Comptroller of the Stale of New York directly to the provider(s) of such services. | HEREBY AUTHORIZE AND DIRECT the Crime Victims Board to provide information about my claim to the Crime Victims Assistance Program listed in the Victim Assistance Information Section of this affidavit. A photocopy of this authorization shall be considered as effective and valid as the original. Signature of Claimant State of New York County of On this day of 19. before me came lo me known to be the individual described tn and who execuled the foregoing instrument and acknowledged (hat (s)he executed the same. Notary Public CVBMIS-PI01 Rev 05/15/98 NYC-WTC_000137350