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Notice Of Right To Request Waiver Of Deductible JD-VS-23 - Connecticut
| Notice Of Right To Request Waiver Of Deductible Form. This is a Connecticut form and can be used in Victim Services Statewide . |
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NOTICE OF RIGHT TO REQUEST WAIVER OF DEDUCTIBLE JD-VS-23 Rev. 6-08 C.G.S. ยง 54-210(a)(5) STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov/crimevictim Instructions 1. This form must be completed and signed for consideration of waiver. 2. Keep a copy for your records. 3. 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 Claims Examiner State law requires that the Office of Victim Services (OVS) deduct $100 from every claim that receives compensation. However, OVS may waive the deductible under Connecticut General Statutes Section 54-210 (a)(5). Please check one box and indicate your relationship to the claimant: I am requesting a waiver of the $100 deductible, and I have written below why the deductible should be waived. I am not requesting a waiver of the $100 deductible (please note there will be a one time $100 deduction from the amount of compensation awarded). (Self, mother, father, guardian, etc ) Request For Waiver of Deductible I request that OVS waive the $100 deductible. I believe the $100 deductible should be waived because (you may attach additional pages if necessary): Print name: Date signed: Signed: American LegalNet, Inc. www.FormsWorkflow.com
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