"Victim/Claimant's Authorization" - New York

Victim/Claimant's Authorization is a legal document that was released by the New York State Office of Victim Services - a government authority operating within New York.

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Download "Victim/Claimant's Authorization" - New York

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ANDREW M. CUOMO
ELIZABETH CRONIN, ESQ.
Governor
Director
Claim #: _________________________
Claimant Name: __________________________________
Victim/Claimant’s Authorization:
I ACKNOWLEDGE that accepting an award from the Office of Victim Services (OVS) creates a lien in favor of the State
of New York on any recovery relating to the crime upon which this claim is based, including any judgment, settlement or
order of restitution. I further authorize any funeral director, attorney, employer, police or other public authority, insurance
company or any person who rendered services to the above, or having knowledge of the same, to furnish the OVS or its
representatives the following information: Workers’ Compensation records, information relating to the crime or any
injuries or death suffered as the result of the crime, and information relating to this claim. If an award is made, I authorize
the OVS to make payments directly to the provider of services. I also authorize the OVS to share my information and
records compiled for this claim with the local Victim Assistance Program (VAP) in order for the VAP to assist the OVS in
processing my claim and making its determination. If a private lawyer has been indicated in my application, I also
authorize the OVS to share my information and records compiled for this claim with the lawyer in order for him/her to act
as my representative. I understand a separate Notice of Appearance from my lawyer will be needed in addition to this
authorization. If a family member, friend or other person is indicated in my application, I authorize the OVS to share my
information and records compiled for this claim with that person in order that they assist me with this claim.
A photocopy of this authorization shall be deemed as effective as the original.
(
)
Claimant’s Signature
Date
Daytime Phone #
Email:
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210
800-247-8035 ovs.ny.gov
ANDREW M. CUOMO
ELIZABETH CRONIN, ESQ.
Governor
Director
Claim #: _________________________
Claimant Name: __________________________________
Victim/Claimant’s Authorization:
I ACKNOWLEDGE that accepting an award from the Office of Victim Services (OVS) creates a lien in favor of the State
of New York on any recovery relating to the crime upon which this claim is based, including any judgment, settlement or
order of restitution. I further authorize any funeral director, attorney, employer, police or other public authority, insurance
company or any person who rendered services to the above, or having knowledge of the same, to furnish the OVS or its
representatives the following information: Workers’ Compensation records, information relating to the crime or any
injuries or death suffered as the result of the crime, and information relating to this claim. If an award is made, I authorize
the OVS to make payments directly to the provider of services. I also authorize the OVS to share my information and
records compiled for this claim with the local Victim Assistance Program (VAP) in order for the VAP to assist the OVS in
processing my claim and making its determination. If a private lawyer has been indicated in my application, I also
authorize the OVS to share my information and records compiled for this claim with the lawyer in order for him/her to act
as my representative. I understand a separate Notice of Appearance from my lawyer will be needed in addition to this
authorization. If a family member, friend or other person is indicated in my application, I authorize the OVS to share my
information and records compiled for this claim with that person in order that they assist me with this claim.
A photocopy of this authorization shall be deemed as effective as the original.
(
)
Claimant’s Signature
Date
Daytime Phone #
Email:
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210
800-247-8035 ovs.ny.gov