Form JD-VS-28 "Application for Waiver of Two Year Filing Requirement" - Connecticut

What Is Form JD-VS-28?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2011;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-VS-28 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-VS-28 "Application for Waiver of Two Year Filing Requirement" - Connecticut

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APPLICATION FOR WAIVER OF
STATE OF CONNECTICUT
TWO YEAR FILING REQUIREMENT
OFFICE OF VICTIM SERVICES
JD-VS-28 Rev. 8-11
JUDICIAL BRANCH
C.G.S. § 54-211
www.jud.ct.gov/crimevictim
Instructions
1. Print or type the information requested.
2. The form must be signed by the person who signed the application for victim compensation.
3. Keep a copy for your records.
4. Mail to the address below or fax to 860-263-2780.
Mail to: Office of Victim Services, 225 Spring Street, Fourth Floor, Wethersfield, CT 06109
Name of Victim
Claim Number
Name of claimant or person filing for claimant
Claims examiner
Check the appropriate box:
The claimant was a minor at the time of the criminal incident and the application was filed late through no fault of the
minor (Section 54-211(a)(3) of the Connecticut General Statutes).
The claimant was an adult at the time of the criminal incident and the application was filed late because the criminal
incident caused physical, emotional, or psychological injuries (Section 54-211(a)(2) of the Connecticut General
Statutes). Describe the physical, emotional, or psychological injuries (you may attach more pages, if needed):
Print name
Date signed
Signature (Parent or guardian if claimant is a minor)
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with
the ADA, contact the Office of Victim Services at the address shown above.
Print Form
Reset Form
APPLICATION FOR WAIVER OF
STATE OF CONNECTICUT
TWO YEAR FILING REQUIREMENT
OFFICE OF VICTIM SERVICES
JD-VS-28 Rev. 8-11
JUDICIAL BRANCH
C.G.S. § 54-211
www.jud.ct.gov/crimevictim
Instructions
1. Print or type the information requested.
2. The form must be signed by the person who signed the application for victim compensation.
3. Keep a copy for your records.
4. Mail to the address below or fax to 860-263-2780.
Mail to: Office of Victim Services, 225 Spring Street, Fourth Floor, Wethersfield, CT 06109
Name of Victim
Claim Number
Name of claimant or person filing for claimant
Claims examiner
Check the appropriate box:
The claimant was a minor at the time of the criminal incident and the application was filed late through no fault of the
minor (Section 54-211(a)(3) of the Connecticut General Statutes).
The claimant was an adult at the time of the criminal incident and the application was filed late because the criminal
incident caused physical, emotional, or psychological injuries (Section 54-211(a)(2) of the Connecticut General
Statutes). Describe the physical, emotional, or psychological injuries (you may attach more pages, if needed):
Print name
Date signed
Signature (Parent or guardian if claimant is a minor)
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with
the ADA, contact the Office of Victim Services at the address shown above.
Print Form
Reset Form