M IS NOVEMBER 1, 2012
To assist us in responding to your claim as soon as possible, please help us by completing the information requested in the form below. If you need assistance in completing this form, please call or email Phyllis Hanfling at Phyllis.hanfling@state.co.us (303) 866-6395
SECTION 1. VICTIM INFORMATION
First Name: SSN Number: Street Address 1 Street Address 2 City Telephone Number (Day) State Zip Code Telephone Number (Evening/Cell) MI: / / Last Name:
SECTION 3. INFORMATION REGARDING THE VICTIMS PHYSICAL INJURIES (complete this Section if you were physically injured on July 20, 2012)
Were you hospitalized overnight as a result of your injuries sustained on 7/20/12? Yes No Enter the total number of days and nights of hospitalization during the period between 7/20/12 and October 15, 2012? ________________
Did your injuries result in permanent paralysis or brain injury? I have attached documentation to verify the length of my hospitalization (for example, a letter from the hospital or health care provider).
Yes
No
Yes
No
Yes
No
SECTION 6.
PAYMENT
Please mail a check to Claimant at the address shown in Section 1 above. Please provide your telephone contact information below: Telephone No.(Day): Telephone No. (Evening/Cell):
SECTION 7.
I hereby certify that the information provided in this application is true and accurate to the best of my knowledge. Signature of Claimant on this Claim Form does not Constitute a Waiver of any Legal Rights.
The foregoing instrument was subscribed and sworn before me this ___ day of __________, 2012, by ________________________________________________________________________________________________. My Commission Expires: Affix Notary Seal Here:
DATE:
Please Return Completed Claim Form via U.S mail to: Aurora Victim Relief Fund Program Kenneth R. Feinberg, Fund Administrator c/o Office of the Governor of the State of Colorado 136 State Capitol Denver, CO 80203 Or Email: c/o Phyllis.hanfling@state.co.us