Free APPLICATION FOR WAIVER OF TWO YEAR FILING REQUIREMENTS - Connecticut

APPLICATION FOR WAIVER OF TWO YEAR FILING REQUIREMENT
JD-VS-28 Rev. 6-08 C.G.S. § 54-211

OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov/crimevictim

STATE OF CONNECTICUT

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. Forward original to the Office of Victim Services at the address shown below.

FROM: Office of Victim Services, 225 Spring Street, Fourth Floor, Wethersfield, CT 06109
Name of Victim Name and Address of Claimant Claim Number Relationship to Victim (self, mother, father, guardian, etc )

Please check the appropriate box: As an ADULT, my application was filed late because of physical, emotional or psychological injuries that were as a result of the criminal incident. (C.G.S. § 54-211(a)(2)) As a MINOR, my application was filed late through no fault of my own. (C.G.S. § 54-211(a)(3)) Please explain why you believe the two-year-waiver should be granted: (You may attach additional pages, if necessary)

Print name: Date signed:
PRINT

Signed:

(Parent or guardian if victim is a minor)

RESET