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Decedent's SSN or Nat'l ID #
OMB 1123-0012
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SEPTEMBER 11TH VICTIM COMPENSATION FUND
ELIGIBILITY FORM FOR DECEASED INDIVIDUALS
Eligibility Form
(Parts I- IV)
PART I. INFORMATION ABOUT THE CLAIM AND DECEDENT
A.
GENERAL INFORMATION ABOUT THE DECEDENT (AS OF THE TIME OF DEATH)
Decedent's Last Name
First Name
Middle Name
Mailing Address
Mailing Address
Apartment/Suite Number
City
Zip/Postal Code
Country
/
State/Province
/
/
Date of Birth (mm/dd/yyyy)
/
Date of Death (mm/dd/yyyy)
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Country of Citizenship
Social Security or National ID Number
Passport Country (if not U.S.)
Passport Number (if not U.S. and available)
Marital status at time of death:
Married
Widowed
Separated
Divorced
Single
Other. Please explain:
6837529033
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
B. INFORMATION ABOUT THE DECEDENT'S PERSONAL REPRESENTATIVE
The Personal Representative is the only person who can submit a claim to the Victim Compensation Fund for a
Decedent. To be a Personal Representative, you generally must be appointed by a court as (a) the Personal
Representative, (b) the Executor of the Decedent's will, or (c) the Administrator of the estate. In some limited
instances, where a court has not made such an appointment and such issue is not the subject of a pending
dispute, the Special Master may appoint a Personal Representative for the Fund.
I have been appointed by a court as (a) the Personal Representative, (b) the Executor of the Decedent's will or
(c) the Administrator of the Decedent's estate. (Please submit original court order or Letter of Administration)
I understand that in most cases the Personal Representative should be the individual already appointed by a
court, but I have been unable to be appointed Personal Representative, Executor or Administrator by a court and
hereby request that the Special Master appoint me as Personal Representative for this fund.
Please describe below why you have been unable to be appointed as Personal Representative. Also, please
submit a certified copy of the Decedent's will (if one exists) showing you are named the executor, as well as
relevant filings. If no will exists, submit (a) relevant proof of your relationship to the Decedent and (b) proof
that you are the first person in line of succession under the laws of intestacy in the Decedent's domicile:
Explanation
Explanation
Explanation
Are you aware of anyone else who has been named Executor of the Decedent's will or who has been
appointed or has applied to be appointed as (a) the Personal Representative, (b) the Executor of the
Decedent's will, or (c) the Administrator of the Decedent's estate?
Yes
No
If yes, please explain
Explanation
Explanation
Explanation
Personal Representative’s Last Name
First Name
Middle Name
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Social Security or National ID Number
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Decedent's SSN or Nat'l ID #
OMB 1123-0012
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B. INFORMATION ABOUT THE DECEDENT'S PERSONAL REPRESENTATIVE (continued)
Mailing Address
Mailing Address
Apartment/Suite Number
City
Zip/Postal Code
Country
State/Province
Email Address
/
/
(
Date of Birth (mm/dd/yyyy)
(
)
)
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Telephone Number (Home)
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(
Telephone Number (Work)
)
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Telephone Number (Mobile)
Country of Citizenship
Passport Number (if not U.S. and available)
Passport Country (if not U.S.)
Please indicate if you would like correspondence to be provided via e-mail. Please note, selecting this option
will require you to register at www.VCF.gov.
0222322586
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
C. INFORMATION ABOUT THE PERSONAL REPRESENTATIVE'S ATTORNEY OR
ALTERNATE CONTACT PERSON (IF APPLICABLE)
If an attorney or other authorized individual is assisting the Personal Representative with this claim, please indicate
and fill out the information below:
Attorney
Other Individual
Title:
Relationship to Personal Representative:
Last Name
First Name
Middle Name
Law Firm or Organization
Mailing Address
Mailing Address
Apartment/Suite Number
City
Zip/Postal Code
Country
State/Province
Email Address
(
)
-
Telephone Number
The Personal Representative should indicate here and complete the certification at Part IV.F (Authorization of
Attorney Communication and Correspondence) if the Personal Representative authorizes the VCF to
communicate with this individual about his/her claim. The Personal Representative may also indicate at Part
IV.F if he/she would like to receive a copy of all VCF written correspondence regarding his/her claim.
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
D. INFORMATION ABOUT THE DECEDENT'S PRIOR CLAIM WITH THE SEPTEMBER 11TH VICTIM
COMPENSATION FUND (IF APPLICABLE)
Was a claim previously filed by or on behalf of the Decendent with the original September 11th Victim
Compensation Fund of 2001?
Yes
No
Do not know
If no, please proceed to Part I.E
If yes,
What injury/injuries did the Decedent allege in connection with the prior claim? Please identify.
Was a payment issued on the claim?
Yes
No
If no, was the claim denied/determined to be ineligible?
Do Not Know
Yes
No
If yes,
What was the basis for the ineligibility determination?
Outside the original Victim Compensation Fund zone
Did not sustain physical harm
Did not sustain physical harm within requisite timeframe
Do not know.
Other reason for ineligibility. Please specify.
For what injury/injuries was the Decedent previously compensated?
Traumatic injury. Please specify.
Respiratory or other latent injury. Please specify.
Other.
Do not know.
Was the Decedent compensated for any disability or future lost wages?
Yes
No
Do Not Know
If yes, was it for a:
Permanent disability
Temporary disability
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Decedent's SSN or Nat'l ID #
OMB 1123-0012
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E. INFORMATION ABOUT THE DECEDENT'S PARTICIPATION IN LAWSUITS RELATED
TO SEPTEMBER 11, 2001 (IF APPLICABLE)
1. Has the Decedent or any dependent, spouse or beneficiary of the Decedent filed a lawsuit or been a party to a
lawsuit in any court for damages as a result of the September 11, 2001 attacks (including damages related to
debris removal)? (Note: Do not include in this section any lawsuit to recover collateral source obligations (such
as insurance or Social Security) or a lawsuit against any person who is a knowing participant in any conspiracy to
hijack or commit any terrorist act.)
Yes
No
If no, please proceed to Part I.E.2 below
If yes,
Was the lawsuit commenced after December 22, 2003?
Yes
No
Has the lawsuit been dismissed or withdrawn?
Yes
No
/
If yes, when was the lawsuit dismissed or withdrawn?
Has the lawsuit been settled?
If yes,
Yes
Date(mm/dd/yyyy)
No
Yes
Did the individual settle all claims?
If yes,
/
No
,
What was the total settlement amount?
What injuries or damages were claimed in the lawsuit? Please specify
If no, have all unsettled claims been dismissed or withdrawn?
Was a release of all claims in such lawsuit tendered (i.e., signed and
submitted) prior to January 2, 2011?
,
Yes
No
Yes
No
If yes,
Who tendered (i.e., signed and submitted) the release?
Decedent
Decedent’s attorney
Did the Decedent's attorney have authority to sign the
(See instructions for
release on the Decedent's behalf?
Yes
No further information.)
2. Has the Decedent filed or has any dependent, spouse or beneficiary of the Decedent filed on the Decedent's behalf
any other lawsuit or claim with any court or bankruptcy trust for any respiratory injury or disease due to exposure
unrelated to September 11, 2001? (An example would be a lawsuit for injuries related to exposure to asbestos.)
If no, please proceed to Part II
If yes,
Please provide information on any lawsuit or claim (complete for each lawsuit or claim)
Court/Trust:
Year Filed:
Docket number:
Injury/disease claimed:
Do not know:
Has the lawsuit or claim been completely resolved?
Yes
No
If yes, please provide documentation of the judgment, settlement or trust compensation
Yes
No
If no, has the lawsuit or claim been resolved in part?
0315541065
If yes, please provide documentation of the judgment, settlement or trust compensation
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
PART II. INFORMATION ABOUT THE DECEDENT'S PRESENCE AT A 9/11 CRASH
SITE BETWEEN SEPTEMBER 11, 2001 AND MAY 30, 2002
In this Part, please identify the circumstances and locations (Section A) and corresponding time and duration
(Section B) of Decedent's presence at a 9/11 crash site from September 11, 2001 through May 30, 2002
Note: If the Decedent’s presence at the 9/11 Crash Site from
September 11, 2001 to May 30, 2002 involved more than one
location (for example, if Decedent was a Responder at the
WTC and also resided in the NYC Exposure Zone, or if
Decedent worked at two different buildings within the NYC
Exposure Zone), please complete this Part II for each location.
If you are submitting a hard copy claim form please make
copies of this Part II of the claim form and submit multiple
copies of this Part II.
What is the definition of a “Responder” for purposes of
this claim form?
A “Responder” is defined as an individual who performed
rescue, recovery, demolition, debris cleanup or other related
services in the NYC Exposure Zone (defined below), at the
Pentagon site or at the Shanksville, PA site, in response to
the September 11, 2001 terrorist attacks, regardless of
whether the individual was a state or federal employee or
member of the National Guard or performed the services in
some other capacity. Therefore, a Decedent may be
considered a Responder even if the Decedent performed the
listed services through a private employer or on a volunteer
basis.
What is the “NYC Exposure Zone” for purposes of this
claim form?
For purposes of this claim form, the NYC Exposure Zone is
defined to include:
the area in Manhattan south of the line that runs along
Canal Street from the Hudson River to the intersection of
Canal Street and East Broadway, north on East
Broadway to Clinton Street, and east on Clinton Street to
the East River; and
any area related to or along the routes of debris removal,
such as barges and Fresh Kills landfill.
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site
1. If the Decedent was a Responder within the NYC Exposure Zone
Please indicate the organization(s) for which the Decedent worked as a Responder from the list below.
Fire Department of New York (FDNY) (includes fire and emergency personnel, active or retired)
Police Department of New York City (NYPD) (active or retired)
Port Authority of New York and New Jersey Police (active or retired)
Office of the Chief of the Medical Examiner of New York City
Port Authority Trans-Hudson Corporation (PATH)
New York City morgue.
Please Specify
New York State Law Enforcement (State Troopers)
New York State Department of Environmental Services
Other New York State agency. Please Specify
MTA, Transit Authority
New York City Department of Sanitation
New York City Department of Design and Construction (DDC)
Other New York City agency. Please Specify
Federal Law Enforcement (FBI, etc)
US Corps of Engineers
US Corps of Engineers Contractor (EE&G)
US Corps of Engineers Contractor Phillips and Jordan
U.S. Coast Guard
National Guard
Secret Service
US Environmental Protection Agency
FEMA
Other Federal Agency. Please Specify
Volunteer Organization (including Red Cross and Salvation Army).
Please Specify
Volunteer (non-affiliated)
Please Specify
Union member
Please specify union and local
Utility Company (phone/gas/cable/water/electric)
Construction Company (Steel worker, engineer, transport, debris removal, grappler & excavator, demolition, etc.).
Please Specify
Barge operating company Please Specify
Trucking company
Please Specify
Trash removal company Please Specify
Maintenance company
Please Specify
Dust control company
Please Specify
Pest control company
Please Specify
Clergy
Please Specify
Other
Please Specify
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
Please identify the Decedent's locations within the NYC Exposure Zone during the period beginning
September 11, 2001 through May 30, 2002.
On or adjacent to the pile/in the pit
Note: The "pile" or "pit" refers to the mound of rubble from the collapse of the WTC buildings and surrounding infrastructure
and the geographic area of the collapsed buildings that was the source and location of the long-burning fires.
Please specify location
Office of Chief Medical Examiner
Pier 6
Pier 25
Other Pier
Please specify
Transport barges
Please specify/describe
Other transportation vehicle(s)
Please specify/describe
Staten Island/Fresh Kills Landfill
Please specify/describe
Other.
Please specify/describe
2. If the Decedent was a Responder at the Pentagon
Please identify the organization(s) for which the Decedent worked as a Responder during the period
beginning September 11, 2001 through May 30, 2002.
Federal Law Enforcement (FBI, etc)
US Corps of Engineers
US Corps of Engineers Contractor (EE&G)
US Corps of Engineers Contractor (Phillips and Jordan)
U.S. Coast Guard
National Guard
Secret Service
US Environmental Protection Agency
FEMA
Other Federal Agency. Please Specify
Volunteer Organization (including Red Cross and Salvation Army).
Please Specify
Volunteer (non-affiliated)
Union member
Please Specify
Please specify union and local
Other. Please Specify
Please identify the location at the Pentagon site where the Decedent was present during the period
beginning September 11, 2001 through May 30, 2002
Address
Address
9924259482
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
3. If the Decedent was a Responder at the Shanksville, PA
Please identify the organization(s) for which the Decedent worked as a Responder during the period
beginning September 11, 2001 through May 30, 2002.
Federal Law Enforcement (FBI, etc)
US Corps of Engineers
US Corps of Engineers Contractor (EE&G)
US Corps of Engineers Contractor (Phillips and Jordan)
U.S. Coast Guard
National Guard
Secret Service
US Environmental Protection Agency
FEMA
Other Federal Agency. Please Specify
Volunteer Organization (including Red Cross and Salvation Army). Please Specify
Volunteer (non-affiliated)
Please Specify
Union member
Please specify union and local
Other. Please Specify
Please identify the location at the Shanksville site where the Decedent was present during the period
beginning September 11, 2001 through May 30, 2002
Address
Address
4. If the Personal Representative claims the Decedent's presence at the site based on residence
within the NYC Exposure Zone
Please identify the address of the Decedent's residence during the period beginning
September 11, 2001 through May 30, 2002
Address
Address
2715388778
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
5. If the Decedent worked (as a non-Responder) cleaning buildings or performing maintenance
work within the NYC Exposure Zone
Identify the name, address, telephone number and email address of the Decedent's employer for the
period beginning September 11, 2001 through May 30, 2002 during which you are asserting Decedent's
presence in the NYC Exposure Zone. If the Decedent had more than one employer during this time
period, please print a copy of this page and complete this section separately for each employer.
Employer
Employer's Address
Employer's Address
(
)
Telephone Number
-
Email Address
Please identify the name and address of the location where the Decedent worked.
Please complete this Part separately for each location.
Address
Address
6. If the Decedent worked (as a non-Responder) within the NYC Exposure Zone in a capacity
other than cleaning buildings or performing maintenance work
Identify the name, address, telephone number and email address of the Decedent's employer for the
period beginning September 11, 2001 through May 30, 2002 during which you are asserting Decedent's
presence in the NYC Exposure Zone. If the Decedent had more than one employer during this time
period, please print a copy of this page and complete this section separately for each employer.
Employer
Employer's Address
Employer's Address
(
)
Telephone Number
-
Email Address
Please identify the name and address of the location where the Decedent worked (if not same as above).
Please complete this section separately for each location.
Address
Address
2855073606
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
7. If the Decedent attended school or a child care or adult care facility within the NYC Exposure Zone.
Identify the name of the school or the child care or adult day care facility that the Decedent attended in
the NYC Exposure Zone for the period beginning September 11, 2001 through May 30, 2002.
School/care facility name
School/care facility address
School/care facility address
(
)
Telephone Number
-
8. If the Decedent was present within the NYC Exposure Zone in some other capacity
(e.g., as a visitor).
Please describe why the Decedent was in the NYC Exposure Zone during the period beginning
September 11, 2001 through May 30, 2002:
Description
Description
Description
Description
Please identify the closest location within the NYC Exposure Zone where the Decedent was present during
the period beginning September 11, 2001 through May 30, 2002:
Building - identify address
Street - identify address/cross street
Subway/train/station - indentify location
Other - specify location
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
9. If the Decedent was present at the Pentagon site (as non-Responder).
Why was the Decedent present at the Pentagon site during the period beginning September 11, 2001
through May 30, 2002?
Worked at Pentagon
Attended meeting at Pentagon
Other. Please explain
Identify the name, address, telephone number and email address of the Decedent's employer for the
period beginning September 11, 2001 through May 30, 2002 during which the Decedent's presence is
claimed at the site.
Employer Name
Employer's Address
Employer's Address
(
Telephone Number
)
-
Email Address
Identify the location at the Pentagon site where the Decedent was present during the period beginning
September 11, 2001 through May 30, 2002.
Address
Address
Address
4655319340
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
B. Time and Duration of Presence at the Site.
Please identify on the lines below the specific days and number of hours for each day beginning
September 11, 2001 through May 30, 2002 that presence at the site is asserted at the location(s)
indentified in Part II.A (e.g., lived, worked, attended school or was otherwise present at a 9/11 crash
site).
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Start Date: (mm/dd/yyyy)
Start Date: (mm/dd/yyyy)
Start Date: (mm/dd/yyyy)
Start Date: (mm/dd/yyyy)
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
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End Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
C. Proof of Location and Time of Presence and Activities at the Site.
Please see the instructions and document checklist for an explanation of the documents that you
must submit to prove that the Decedent was present at a 9/11 crash site.
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
PART III. INFORMATION ABOUT THE DECEDENT'S DEATH
Was the Decedent's death a result of the terrorist-related aircraft crashes of September 11, 2001 or the
Yes
No
debris removal efforts that took place in the immediate aftermath of those crashes?
If no, proceed to Part IV
If yes,
Was the Decedent's death a result of one of the following conditions? Please indicate
all that apply and answer questions 1 - 7 for each condition on the following pages.
Make an additional copy of pages 16 - 18 for each condition being reported.
01 - Interstitial lung diseases
Primary cause
Contributing cause
02 - Chronic respiratory disorder – Fumes/Vapors
Primary cause
Contributing cause
03 - Asthma
Primary cause
Contributing cause
04 - Reactive airways dysfunction syndrome (RADS)
Primary cause
Contributing cause
05 - WTC-exacerbated chronic obstructive pulmonary disease (COPD)
Primary cause
Contributing cause
06 - Chronic cough syndrome
Primary cause
Contributing cause
07 - Upper airway hyperreactivity
Primary cause
Contributing cause
08 - Chronic rhinosinusitis
Primary cause
Contributing cause
09 - Chronic nasopharyngitis
Primary cause
Contributing cause
10 - Chronic laryngitis
Primary cause
Contributing cause
11 - Gastroesophageal reflux disorder (GERD)
Primary cause
Contributing cause
12 - Sleep apnea exacerbated by or related to the above conditions.
Primary cause
Contributing cause
13 - Other musculoskeletal disorders
Primary cause
Contributing cause
14 - Traumatic injury
Primary cause
Contributing cause
15 - Other. If other, please identify and explain how the death was a result of the 9/11 crashes.
If you are claiming multiple conditions, please use the condition number to indicate for
which condition the questions are being answered on the following pages.
Please remember to submit all pages.
4476174913
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Decedent's SSN or Nat'l ID #
OMB 1123-0012
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Was the Decedent's death a result of the terrorist-related aircraft crashes of September 11, 2001 or
the debris removal efforts that took place in the immediate aftermath of those crashes?
(continued)
Condition Number:
Please answer the following questions.
1. When did the Decedent first discover this injury or condition?
/
/
/
/
/
/
(mm/dd/yyyy)
2. When was the Decedent first treated by a medical
professional for this injury or condition?
3. When was the Decedent diagnosed with this injury or
condition?
4. Was the Decedent treated for this injury or condition
under the WTC Health Program which commenced on
July 1, 2011?
(mm/dd/yyyy)
(mm/dd/yyyy)
Yes
No
What is the WTC Health Program?
The WTC Health Program, which is operated by the National Institute for
Occupational Safety and Health (NIOSH), was established pursuant to Title
I of the Zadroga Act and commenced on July 1, 2011. The WTC Health
Program provides medical diagnostic and treatment services for eligible
individuals with specified injuries or conditions determined to be
aggravated, contributed to, or caused by the September 11, 2001 terrorist
attacks or the subsequent debris removal efforts. The WTC Health
Program includes a nationwide network of health care providers for eligible
individuals living outside the New York metropolitan area. As of July 1,
2011, the WTC Health Program assumed the functions and goals of two
prior programs: the WTC Medical Monitoring and Treatment Program for
responders and recovery and cleanup workers which included a nationwide
network of health care providers who provided services for responders
living outside the New York metropolitan area, and the WTC Environmental
Health Center Community Program for eligible residents, students, and
others in the community. Please refer to the Instructions for more
information about the WTC Health Program and the two previous
programs.
continued on next page
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
Please restate the conditon number being reported on
Condition Number:
If, yes,
At what medical location in the WTC Health Program was the Decedent treated for this injury or condition?
Fire Department of New York (FDNY)
Long Island Jewish Medical Center
Mount Sinai School of Medicine - Annenberg Building (New York, NY)
Mount Sinai School of Medicine - Richmond University Medical Center (Staten Island, NY)
Nationwide Network of Health Care Providers. Please specify
New York University, Bellevue Hospital Center
State University of New York, Stony Brook - Suffolk County (Islandia, NY)
State University of New York, Stony Brook - Nassau County (Garden City, NY)
State University of New York, Stony Brook - Nassau County (Hicksville, NY)
State University of New York, Stony Brook - Kings County (Brooklyn, NY)
University of Medicine and Dentistry of New Jersey
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Bellevue Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Elmhurst Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Gouverneur Healthcare Services
5. Was the Decedent treated for this injury or condition prior to July 1, 2011 under the WTC Medical Monitoring
and Treatment Program (including a nationwide network of health care providers who provided services for
responders living outside of the New York City metropolitan area) or the WTC Environmental Health Center
Yes
No
Community Program?
If yes,
At what medical location was the Decedent treated for this injury or condition?
City University of New York/Queens College
Fire Department of New York (FDNY)
Mount Sinai School of Medicine - Annenberg Building (New York, NY)
Mount Sinai School of Medicine - Richmond University Medical Center (Staten Island, NY)
Nationwide Network of Health Care Providers. Please specify
New York University, Bellevue Hospital Center
State University of New York, Stony Brook - Suffolk County (Islandia, NY)
State University of New York, Stony Brook - Nassau University Medical Center (East Meadow, NY)
State University of New York, Stony Brook - Nassau County (Hicksville, NY)
University of Medicine and Dentistry of New Jersey
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Bellevue Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Elmhurst Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Gouverneur Healthcare Services
3258547701
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Decedent's SSN or Nat'l ID #
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OMB 1123-0012
Please restate the conditon number being reported on
Condition Number:
6. Was the Decedent treated for this injury or condition by another entity/program or by a private
physician?
Yes
No
If yes:
Please identify the outside physician(s) or other entity/program treating the Decedent for this
condition. Include the contact information (name, address, telephone number, email address)
of the outside physician or other entity/program.
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
(
)
-
)
-
Telephone Number
Email Address
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
(
Telephone Number
Email Address
7. Please submit Decedent's death certificate and any other medical documents showing Decedent's cause
of death. You may also need to submit the Decedent's certified medical records related to this injury or
condition. Please see the Instructions and the Document Checklist for more information.
If you are asserting additional conditions, please print copies of pages 16 - 18 and complete the
questions for each condition asserted. Please remember to submit all pages.
8622047054
18
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
-
PART IV. ATTESTATIONS AND CERTIFICATIONS FOR ELIGIBILITY
FORM
A. PRIVACY ACT NOTICE
The Department of Justice is authorized to collect this information by the September 11th Victim
Compensation Fund of 2001, Title IV of Public Law 107-42, Air Transportation Safety and System
Stabilization Act, 49 U.S.C. § 40101 note, as amended by the James Zadroga 9/11 Health and
Compensation Act of 2010, Title II of Public Law 111-347. The information you submit in your claim is for
official use by the U.S. Department of Justice for the purposes of determining your eligibility for and the
amount of compensation you may receive under your claim to the Victim Compensation Fund. Provision of
this information is voluntary; however, failure to provide complete information may result in a delay in
processing or a denial of your claim. Information you submit regarding your claim may be disclosed by the
Government only in accordance with the provisions of the Privacy Act.
I Authorize the U.S. Department of Justice to disclose any records or information relating to my Victim
Compensation Fund claim for the purpose of determining qualification and/or compensation of my claim to:
agency contractors assisting in the administration of the Victim Compensation Fund; other federal, state, or local
agencies, including the Department of Treasury and NIOSH; and other individuals or entities having information
related to the claim, such as physicians, medical service providers, insurers, and employers.
/
Signature of Personal Representative
/
Date (mm/dd/yyy)
Print Name
B. P ROOF
OF
D ISMISSAL OF ANY L AW SUIT
Have you or any dependent, spouse, or beneficiary of the Decedent filed a lawsuit (or been a party to a
lawsuit) in any Federal or State court relating to or arising out of damages sustained as a result of the
terrorist-related aircraft crashes of September 11, 2001 or for damages arising from or related to debris
removal (other than a lawsuit to recover collateral source obligations or a lawsuit against any person who is a
knowing participant in any conspiracy to hijack any aircraft or commit any terrorist act)?
Yes
No
If Yes,
Was the lawsuit withdrawn or dismissed on or before January 2, 2012?
Yes
No
Was the lawsuit settled on or before January 2, 2011?
Yes
No
Was the lawsuit settled in part on or before January 2, 2011?
Yes
No
Do not know
If yes:
Was the portion of the lawsuit that was not settled on or before January 2, 2011
Yes No
dismissed on or before January 2, 2012?
Initial here:
0640489674
19
-
Decedent's SSN or Nat'l ID #
OMB 1123-0012
-
C. A CKNOWLEDGEMENT OF W AIVER OF R IGHTS
I hereby acknowledge that by submission of a substantially complete Eligibility Form, I am waiving the right
to file a lawsuit (or be a party to a lawsuit) in any federal or state court for damages sustained as a result of the
terrorist-related aircraft crashes of September 11, 2001 or for damages arising from or related to debris
removal.
Please note this Waiver of Rights could apply to the rights of individuals other than the Personal
Representative. This waiver does not apply to lawsuits to recover collateral source obligations or to a lawsuit
against any person who is a knowing participant in any conspiracy to hijack any aircraft or commit any terrorist
attack.
/
Signature of Personal Representative
/
Date (mm/dd/yyy)
Print Name
D. A UTHORIZATION
OF
R ELEASE
OF I NFORM ATION
I Authorize the U.S. Department of Justice to obtain any information relating to my claim under the September
11th Victim Compensation Fund of 2001 (Victim Compensation Fund or VCF) for the purpose of evaluating my
claim for compensation to the VCF from individuals, employers, hospitals, medical service providers, other
federal, state or local agencies including the Social Security Administration and the Internal Revenue Service,
the World Trade Center Health Program (WTCHP), the National Institute for Occupational Safety and Health
(NIOSH), the Clinical Centers of Excellence under the WTCHP, the Nationwide Network of health care
providers under the WTCHP, the Fire Department of New York, the New York Police Department, the New
York Office of Payroll Administration, the New York City Employees' Retirement System, the Teachers'
Retirement System of the City of New York, the New York City Police Pension Fund, the New York Fire
Department Pension Fund, the New York City Board of Education Retirement System, the New York State
Workers' Compensation Board, the State of New Jersey Department of Labor and Workforce Development,
Division of Workers' Compensation, the State of Connecticut Department of Social Services, Bureau of
Rehabilitation Services (formerly the State of Connecticut Workers' Compensation Commission), the Port
Authority of New York and New Jersey, the New York City Office of the Chief Medical Examiner, New York
City Health and Hospitals Corporation, Child Health Plus, Family Health Plus, Medicaid, the WTC Captive
Insurance Company, Inc., the Allocation Neutral for the World Trade Center Litigation Settlement, or other
sources having information relating to my claim. This information may include, but is not limited to, medical,
government, and financial information (including pension records, pension files, or pension information) about
me or the Decedent whom I represent. The requested medical information may consist of the Decedent's
entire medical records, which may include application or enrollment information, eligibility information, claims
records, claim status, patient medical records, patient histories, office notes (except psychotherapy notes), test
results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent by
other health care providers. Disclosure requested will include otherwise confidential information. If records
include claims or other information pertaining to chronic diseases, behavioral health conditions, including
alcohol or substance abuse, communicable diseases, including HIV/AIDS, and/or genetic marker information,
these records will be included in the information made available to the Victim Compensation Fund.
0522528857
20
-
Decedent's SSN or Nat'l ID #
D. A UTHORIZATION
OF
R ELEASE
OMB 1123-0012
-
OF I NFORM ATION ( CONTINUED )
I Recognize that signing this Authorization is voluntary and that the Decedent's doctors and medical providers
and any other entity in possession of Decedent's health information may not condition treatment, payment,
enrollment or eligibility for benefits on whether I sign this Authorization. However, the VCF may not be able to
evaluate my claim if I do not authorize the release of the Decedent's medical records.
I Further Recognize that health care providers are required by the Privacy Rule under HIPAA to protect the
Decedent's health information. When they provide the information to the VCF it will not be protected by this same
Privacy Rule. However, the VCF, DOJ and NIOSH will continue to protect the confidentiality of the Decedent's
medical records to the extent they are permitted to do so under another federal law, the Privacy Act. The VCF
will not disclose the Decedent's identifiable health information that it receives under this Authorization without my
written consent except where authorized to do so by law.
I Further Authorize the U.S. Department of Justice to disclose any records or information relating to my Victim
Compensation Fund claim for the purpose of determining qualification and/or compensation of my claim to:
agency contractors assisting in the administration of the Victim Compensation Fund; other federal, state, or local
agencies, including the Department of Treasury and NIOSH; and other individuals or entities having information
related to the claim, such as physicians, medical service providers, insurers, and employers.
I Further Authorize the U.S. Department of Justice to publish the name of the Personal Representative filing a
claim and the name of the Decedent for whom compensation is sought.
I Further Authorize the release of information relating to my claim, where such information indicates a violation
or potential violation of law, including submission of fraudulent claims, to any civil or criminal law enforcement
authority or other appropriate agency charged with responsibility of investigating or prosecuting such a violation.
I Further Authorize individuals, entities, and federal, state and local agencies including NIOSH and the WTCHP,
having information pertinent to my claim to release such information to a duly accredited representative of the
Department of Justice during the review of my claim to the Victim Compensation Fund, regardless of any
previous agreement to the contrary. Copies of this authorization that show my signature are as valid as the
original release signed by me. I acknowledge that I have the right to revoke this Authorization at any time, except
to the extent that VCF and the entities listed above have already acted based on this Authorization. I understand
that to revoke this authorization, I must write to the VCF at September 11th Victim Compensation Fund, P.O. Box
34500, Washington, D.C. 20043. I recognize that this authorization is valid for six (6) years from the date signed
or upon my written termination whichever is sooner.
I Certify that I am the person named below (Personal Representative making a claim to the Victim Compensation
Fund on behalf of the Decedent) and I authorize the release of information listed above. I understand that the
knowing and willful request for or acquisition of a record pertaining to an individual under false pretenses is a
criminal offense subject to a $5,000 fine.
By initialing, I acknowledge that the information described above may include mental health information and I
authorize the release of such information ____________.
/
Date (mm/dd/yyyy)
Signature of Personal Representative
Print Name
1775199346
21
/
-
Decedent's SSN or Nat'l ID #
OMB 1123-0012
-
E. PERSONAL REPRESENTATIVE’S ACKNOWLEDGMENT OF ATTORNEY’S COMPLIANCE WITH
LIMITATION ON ATTORNEY FEES
If an attorney has rendered services in connection with this claim, the Personal Representative must sign and
date the following acknowledgement:
I hereby acknowledge that I have read and understand the provisions governing the limitation on attorney
fees as stated in the Instructions to this claim form, which, in general and with limited exceptions, provide that
my attorney, notwithstanding any contract, cannot charge me more than ten percent (10%) of any award
that may be paid on my claim, and that any expenses incurred by my attorney in connection with my claim,
other than those that are routinely incurred, cannot be charged to me unless they have been approved by the
Special Master.
/
/
Date (mm/dd/yyyy)
Signature of Personal Representative
Print Name
F. A UTHORIZATION
FOR
A TTORNEY C OMMUNICATION
AND
C ORRESPONDENCE
If an attorney or other authorized individual is assisting the Personal Representative with this claim and the
Personal Representative wants to authorize the Victim Compensation Fund to communicate with this
individual, please sign and date the following authorization.
Indicate
here
If you would like to receive a copy of all VCF correspondence regarding this claim.
Note that if you do not check this box, the VCF will not be authorized to contact you
directly regarding this claim.
I Authorize the Special Master, the Special Master's designees, the United States Department of Justice or
agency contractors assisting in the administration of the Victim Compensation Fund to contact my attorney or
other persons authorized to act on my behalf (if identified in Part I.C.) if the Special Master needs additional
information or clarification about my claim.
/
Date (mm/dd/yyyy)
Signature of Personal Representative
Print Name
1394245109
22
/
Decedent's SSN or Nat'l ID #
G. C ERTIFICATION
OF
-
-
OMB 1123-0012
A CCURACY OF INFORM ATION
I hereby certify that the information provided in this application and any documents provided in support of this
claim are true and accurate to the best of my knowledge, and I agree that any payment made by the VCF is
expressly conditioned upon the truthfulness and accuracy of the information and documentation provided in
support of the claim. Further, I understand that false statements or claims made in connection with this
application may result in fines, imprisonment and/or any other remedy available by law to the Federal
Government, and that claims that appear to be potentially fraudulent or to contain false information will be
forwarded to federal, state, and local law enforcement authorities for possible investigation and prosecution.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
, 201
day of
.
Signature of Personal Representative
Print Name
H. P APERWORK R EDUCTION A CT N OTICE
An agency may not conduct or sponsor an information collection and a person is not required to respond to
a collection of information unless it contains a currently valid OMB approval number. We try to create forms
and instructions that are accurate, can be easily understood, and that impose the least possible burden on
you. The estimated average time to complete and file this application is 1.5 hours. If you have comments
regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the
Office of the Special Master, U.S. Department of Justice, 950 Pennsylvania Ave, NW, Washington, DC
20530; OMB control number 1123-0012. (Do not mail your completed application to this address.)
1230260330
23
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Deceased Individuals
Authorization for Release of Medical Records
Instructions for Personal Representative - Please list all doctors and health care providers who were
involved in diagnosing and treating your injury, as well as any other entities (e.g., insurance companies,
workers' compensation programs, pension programs) that may have medical information in Section 1.
Please copy this exhibit and complete if you need to list more than four health care providers or other
entities. Then, please print your name and address and sign in the block in Section 2.
When you sign this document, you give permission to the Decedent's doctors, health care
providers or other entities listed below to disclose your health information to the September 11th
Victim Compensation Fund (VCF), the United States Department of Justice (DOJ), and the National
Institute for Occupational Safety and Health (NIOSH) for purposes of evaluating your claim for
compensation to the VCF.
Please note that you may revoke this Authorization at any time, except to the extent that VCF and the
providers listed below have already acted based on this Authorization. To revoke this authorization, you
must write to the providers or entities listed below and to the VCF at the address below. This
authorization is valid for six (6) years from the date signed or upon your written termination, whichever is
sooner.
The Decedent's providers and certain other entities are required by the Privacy Rule under HIPAA to
protect your health information. When they provide the information to the VCF it will not be protected by
this same Privacy Rule. However, the VCF, the DOJ and NIOSH will continue to protect the
confidentiality of your medical records to the extent they are permitted to do so under another Federal
law, the Privacy Act. The VCF will not disclose your identifiable health information that it receives under
this Authorization without your written consent except where authorized to do so by law.
Information to be disclosed to the Victim Compensation Fund includes, but is not limited to,
application or enrollment information, eligibility information, claims records, claim status, pension
records and files, entire patient medical records, patient histories, office notes (except
psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records,
insurance records, and records sent to your doctors and medical care providers by other health
care providers.
Disclosure requested will include otherwise confidential information. If records include claims or
other information pertaining to chronic diseases, behavioral health conditions, including alcohol or
substance abuse, communicable diseases, including HIV/AIDS, and/or genetic marker information, these
records will be included in the information made available to the VCF.
I understand that this authorization is voluntary. However, if you refuse to sign this authorization, the
VCF will not be able to process your claim for compensation.
7987305975
24
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Deceased Individuals
Authorization for Release of Medical Records
By initialing, I acknowledge that the information described above may include mental health information and I
authorize the release of such information ____________.
I hereby authorize the person, carrier or other entity listed below to disclose confidential
information about the Decedent listed below to the VCF, the DOJ and NIOSH:
Section 1 - Name, telephone number and email address for doctors, health care providers or other
entities.
Physician/Other Entity or Program:
Doctor/Provider/Entity Name
Doctor/Provider/Entity Address
Doctor/Provider/Entity Address
Suite Number
City
State/Province
Zip/Postal Code
(
)
-
(
)
-
Telephone Number
Email Address
Physician/Other Entity or Program:
Doctor/Provider/Entity Name
Doctor/Provider/Entity Address
Doctor/Provider/Entity Address
Suite Number
City
State/Province
Zip/Postal Code
Telephone Number
Email Address
2470624588
25
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Deceased Individuals
Authorization for Release of Medical Records
I hereby authorize the person, carrier or other entity listed below to disclose confidential
information about the Decedent listed below to the VCF, the DOJ and NIOSH:
Section 1 - Name, telephone number and email address for doctors, health care providers or other
entities continued.
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
(
)
-
(
)
-
Telephone Number
Email Address
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
Telephone Number
Email Address
The National Institute for Occupational Safety and Health
9809594307
26
-
Decedent's SSN or Nat'l ID #
OMB 1123-0012
-
Personal Representative's SSN or Nat'lD #
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Deceased Individuals
Authorization for Release of Medical Records
Section 2. - Decedent information
Decedent's Last Name
/
/
-
-
Decedent's Date of Birth
First Name
Middle Name
Decedent's SSN or Nat'l Id #
Address
Address
City
State/Province
Zip/Postal Code
Section 3. - Personal Representative Information and Signature
This information shall be sent to:
The September 11th Victim Compensation Fund
P.O. Box 34500
Washington, DC 20043
I Certify that I am the person named below (Personal Representative making a claim to the Victim
Compensation Fund on behalf of the Decedent) and I authorize the release of information listed above. I
understand that the knowing and willful request for or acquisition of a record pertaining to an individual under
false pretenses is a criminal offense subject to a $5,000 fine.
/
Date (mm/dd/yyyy)
Personal Representative Signature
6760265428
27
/
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
-
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Deceased Individuals
Authorization for Release of Medical Records
Section 3. - Personal Representative Information and Signature (continued)
Personal representative's Last Name
First Name
/
/
-
-
Date of Birth
Middle Name
SSN or Nat'l Id #
Address
Address
City
State/Province
Zip/Postal Code
Type of coverage to which this authorization applies (the doctor, health care provider or other entity will
indicate all that apply)
Medical
Disability
Pharmacy
Long Term Care
Other Please specify/describe
4111546361
28
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit B1 to the Eligibility Form For Deceased Individuals
Authorization for Release of Pension Records and Health Information
by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF PENSION AND HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name
Date of Birth
Social Security Number
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be
released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE,
MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED
INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health
information described below includes any of these types of information, and I initial the line on the box in
Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment
information, the recipient is prohibited from redisclosing such information without my authorization unless
permitted to do so under federal or state law. I understand that I have the right to request a list of people
who may receive or use my HIV-related information without authorization. If I experience discrimination
because of the release or disclosure of HIV-related information, I may contact the New York State
Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212)
306-7450. These agencies are responsible for protecting the my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed
below. I understand that I may revoke this authorization except to the extent that action has already been
taken based on this authorization.
4. I understand that signing this authorization is voluntary. The Decedent's treatment, payment,
enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this
disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted
above in Item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION
OR MEDICAL CARE OR PENSION INFORMATION WITH ANYONE OTHER THAN THE ATTORNEY
OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
6750649030
29
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit B1 to the Eligibility Form For Deceased Individuals
Authorization for Release of Pension Records and Health Information
by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF PENSION AND HEALTH INFORMATION PURSUANT TO HIPAA
7. Name and address of health provider, pension fund, or other entity to release this information:
New York Office of Payroll Administration (OPA)
Room 200N
One Centre Street
New York, NY 10007
New York City Police Pension Fund (POLICE)
233 Broadway, 19th Floor
New York, NY 10279
New York Fire Department Pension Fund (FIRE)
9 MetroTech Center
Brooklyn, NY 11201
New York City Employees' Retirement System (NYCERS)
335 Adams Street, Suite 2300
Brooklyn, NY 11201-3724
Teachers' Retirement System of the City of New York (TRS)
55 Water Street
New York, NY 10041
New York City Board of Education Retirement System (BERS)
65 Court Street, 16th Floor
Brooklyn, NY 11201-4965
8. Name and address of person(s) or category of person to whom this information will be sent:
The September 11th Victim Compensation Fund of 2001
P.O. Box 34500
Washington, DC 20043
The United States Department of Justice
950 Pennsylvania Avenue, NW
Washington, DC 20530
6148342963
30
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit B1 to the Eligibility Form For Deceased Individuals
Authorization for Release of Pension Records and Health Information
by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF PENSION AND HEALTH INFORMATION PURSUANT TO HIPAA
9(a). Specific information to be released:
Complete Pension File, including, but not limited to:
Information regarding the type of pension awarded
(ADR, ODR or service), the amount, and whether or
not the benefit was awarded pursuant to the WTC
Disability Law.
Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV Related Information
Authorization to Discuss Health or Pension Information
9(b).
By initialing here
, I authorize
(Initials)
(Name of individual health care provider, pension fund or other entity)
to discuss my health or pension-related information with my attorney, or a governmental agency,
listed here:
the September 11th Victim Compensation Fund and the United States Department of Justice
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
At request of individual
11. Date or event on which this authorization will
expire:
Six (6) years from the date of signature or upon
my written termination
Other: To evaluate my claim for
compensation with the September 11th
Victim Compensation Fund
12. If not the claimant, name of person signing
form:
13. Authority to sign on behalf of claimant:
All items on this form have been completed and my questions about this form have been answered.
In addition, I have been provided a copy of the form.
Date:
Signature of claimant or representative authorized by law
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which
reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.
8055389042
31
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit B2 to the Eligibility Form For Deceased Individuals
Authorization for Release of Health Information by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name
Date of Birth
Social Security Number
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be
released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE,
MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED
INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health
information described below includes any of these types of information, and I initial the line on the box in
Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment
information, the recipient is prohibited from redisclosing such information without my authorization unless
permitted to do so under federal or state law. I understand that I have the right to request a list of people
who may receive or use my HIV-related information without authorization. If I experience discrimination
because of the release or disclosure of HIV-related information, I may contact the New York State
Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212)
306-7450. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed
below. I understand that I may revoke this authorization except to the extent that action has already been
taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health
plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted
above in Item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION
OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL
AGENCY SPECIFIED IN ITEM 9 (b).
9325070512
32
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit B2 to the Eligibility Form For Deceased Individuals
Authorization for Release of Health Information by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
7. Name and address of health provider or other entity to release this information:
8. Name and address of person(s) or category of person to whom this information will be sent:
The September 11th Victim Compensation Fund of 2001
P.O. Box 34500
Washington, DC 20043
The United States Department of Justice
950 Pennsylvania Avenue, NW
Washington, DC 20530
9639082524
33
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit B2 to the Eligibility Form For Deceased Individuals
Authorization for Release of Health Information by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
9(a). Specific information to be released:
Medical Record from (insert date)
to (insert(date)
Entire Medical Record, including patient histories, office notes (except psychotherapy
notes), test results, radiology studies, films, referrals, consults, billing records, insurance
records, and records sent to you by other health care providers.
Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Other:
Mental Health Information
HIV Related Information
Authorization to Discuss Health Information
9(b).
By initialing here
(Initials)
, I authorize
(Name of individual health care provider)
to discuss my health information with my attorney, or a governmental agency, listed here:
the September 11th Victim Compensation Fund and the United States Department of Justice
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
11. Date or event on which this authorization will
expire:
At request of individual
Other: To evaluate my claim
for compensation with the September
11th Victim Compensation Fund
Six (6) years from the date of signature or upon
my written termination.
12. If not the patient, name of person signing form:
13. Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered.
In addition, I have been provided a copy of the form.
Date:
Signature of patient or representative authorized by law
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which
reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.
8022202433
34
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit C to the Eligibility Form For Deceased Individuals
Attorney Certification of Compliance with Provision on Limitation on Attorney Fees
(Section 104.81)
If the Personal Representative has been represented by an attorney for services rendered in connection with
this claim, Personal Representative's attorney must complete the following certification:
I hereby certify that:
(1) The amount I have charged or will charge for the services I have rendered in connection with this
claim, including expenses routinely incurred in the course of providing legal services, is not more than 10
percent of an award that might be paid on this claim; AND
(2) I have not charged nor will I charge for any expenses incurred in connection with this claim that are
not routinely incurred in the course of providing legal services, unless the Special Master has approved
such expenses; AND
(3) One of the following statements is true concerning a civil action brought by or on behalf of the
Decedent for damages sustained as a result of the terrorist-related aircraft crashes of September 11,
2001 or for damages arising from or related to debris removal (excluding civil actions to recover collateral
source obligations or against any person who is a knowing participant in any conspiracy to hijack or
commit any terrorist act) that was commenced after December 22, 2003 in which a release of all claims in
such action was tendered prior to January 2, 2011:
I did not charge a legal fee in connection with a settlement of this Decdent's claim(s) in
such an action; OR
I charged a legal fee in connection with a settlement of this Decedent's claim(s) in such
an action that was 10 percent or more of the aggregate amount of compensation
awarded though such settlement, and I have not charged nor will I charge for any
services rendered in connection with this claim with the VCF; OR
I charged a legal fee in connection with a settlement of this Decdent's claim(s) in such
an action that was less than 10 percent of the aggregate amount of compensation
awarded though such settlement, and the amount I have charged or will charge for the
services I have rendered in connection with this claim with the VCF does not exceed
the difference between 10 percent of such aggregate amount and the total amount of
all legal fees I charged for services rendered in connection with such settlement.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
, 201
day of
.
Signature of Attorney
Attorney's Name
Attorney's Firm/Address
Attorney's Firm/Address
6447251414
35
-
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit D to the Eligibility Form For Deceased Individuals
Attorney Request for Approval For Charge of Non-Routine Expenses
If the Personal Representative is represented by an attorney and the attorney is seeking expenses incurred
in connection with the claim other than those that are routinely incurred in the course of providing legal
services ("non-routine expenses"), the attorney must request the approval of such expenses by the Special
Master. The Special Master will review such requests on a case-by-case basis.
Indicate here if you are seeking non-routine expenses in connection with
this claim and attach a statement explaining the expenses for which you
seek approval and why they should be approved.
/
/
Date (mm/dd/yyyy)
Signature of Attorney
Attorney's Name
Attorney's Firm/Address
Attorney's Firm/Address
7915042312
36
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit E to Eligibility Form For Deceased Individuals
Notice of Filing Claim
Instructions to Decedent’s Personal Representative:
Fill out a separate copy of this page for each person to whom you are required to provide a Notice of
Filing.
On each copy, fill out the name and address of the person to whom you are providing the Notice and
insert the name of the Decedent in the spaces provided below as indicated.
Deliver each Notice personally or by certified mail, return receipt requested.
You must deliver a copy of this document to the following people:
The immediate family of the Decedent (including, but not limited to, the spouse, former
spouse(s), children other dependents, siblings, and parents)
The Executor or Administrator and beneficiaries of the Decedent’s will and life insurance
policies.
Any other person who may reasonably be expected to assert an interest in an award or to
have a cause or action to recover damages relating to the wrongful death of the Decedent.
TO:
NAME:
ADDRESS:
You are receiving this notice to inform you that a claim on behalf of _________________________________ (insert name of
Decedent) is being filed with the September 11th Victim Compensation Fund of 2001. The claim is being filed by
__________________________________________________________________________ (insert name of Personal
Representative).
The rules that govern the Victim Compensation Fund state that only one claim may be filed in connection with the death of a
Decedent and that the claim must be filed by the Decedent's Personal Representative. The rules also state that any award
from the Victim Compensation Fund shall be paid to the Personal Representative and that the Personal Representative is
required to distribute the award among the Decedent's beneficiaries in accordance with the laws of the Decedent's domicile.
You have been notified that a claim is being filed on behalf of _____________________________________ (insert name of
Decedent) because the Personal Representative is required to give notice of claim filing to the Decedent's immediate family,
to the executor, administrator, and beneficiaries of the Decedent's will and life insurance policies and to other people who
might reasonably have an interest in any award that may be made from the Victim Compensation Fund.
The rules that govern the filing of claims with the Victim Compensation Fund require the Personal Representative waive any
right to file a lawsuit for damages sustained as a result of the terrorist-related aircraft crashes on September 11, 2001 or
debris removal. This waiver could affect the rights of others, including you, to file any such lawsuits.
You are not required to take any action in response to this notice. However, any objection to the filing of the claim must be
made within 30 days after the claim has been filed, which could be a soon as 30 days from the date this notice was mailed or
otherwise provided to you.
If you want to learn more about the Victim Compensation Fund, please call 1-855-885-1555; TDD:1-855-885-1558;
outside the U.S.: 1-212-619-3215. Information can also be obtained over the internet at www.vcf.gov
1742550060
37
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
-
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit F - List of Individuals Notified of Claim Filing
I hereby certify that I have provided the required Notice of Filing of Claim to all the individuals listed below by
either personal delivery or certified mail, return receipt requested, and that I am not aware of anyone else to
whom such notice should be provided.
Signature of Personal Representative
/
/
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
Date (mm/dd/yyyy)
Relationship to Decedent
Mother:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Father:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
4449067284
38
Date of Delivery (mm/dd/yyyy)
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
-
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit F - List of Individuals Notified of Claim Filing
Spouse:
Last Name
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Former Spouse:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Sibling:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
0266394280
39
Date of Delivery (mm/dd/yyyy)
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
-
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit F - List of Individuals Notified of Claim Filing
Sibling:
Last Name
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Child:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Child:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
4349031318
40
Date of Delivery (mm/dd/yyyy)
Decedent's SSN or Nat'l ID #
-
OMB 1123-0012
-
Personal Representative's SSN or Nat'l ID #
September 11th Victim Compensation Fund of 2001
Exhibit F - List of Individuals Notified of Claim Filing
Child:
Last Name
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
/
/
-
-
/
/
/
/
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Partner:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Certified Mail
Return Receipt
Requested
Please describe
Date of Delivery (mm/dd/yyyy)
Other:
Last Name
Date of Birth (mm/dd/yyyy)
First Name
Middle Name
SSN or Nat'l ID # (if available)
Mailing Address
Mailing Address
(
)
Telephone Number
Hand Delivered
-
Date of Delivery (mm/dd/yyyy)
Indicate here if you need more space for Exhibit F
and are submitting additional pages.
3253412763
41
Certified Mail
Return Receipt
Requested
Date of Delivery (mm/dd/yyyy)
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
In order to process your claim, we need certain supporting documents. This checklist will help you compile
those documents. Please categorize your documents by the section of the claim form for which they are being
submitted. You are strongly encouraged to upload your documents electronically, which will allow a more
efficient claims process. If you are submitting a hard copy claim form and would like to upload documents
electronically, you will need to register at www.VCF.gov. Once your hard copy claim form is received,
processed, and loaded to the electronic system, you will have the ability to upload documents. If you do not
have access to electronic copies of documents or do not wish to register at www.VCF.gov, you may submit
hard copies of those documents by mail. To do so, please print this form and on the printed copy, mark the
appropriate boxes in the "Mailed" column for each section that you are submitting. Then send the documents
along with a copy of this form, by mail to September 11th Victim Compensation Fund; P.O. Box 34500;
Washington, DC 20043. The Decedent's Social Security Number or National ID Number and the Personal
Representative's Social Security Number or National ID Number should be written on the top of all documents
submitted by mail. For your records, you should keep a copy of all documents submitted by mail to the VCF.
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part I.B. Information about the Decedent's Personal
Representative
Documentation showing that the Personal
Representative has authority to act on behalf of the
Decedent:
Original Court Order or Letter of Administration
showing your appointment as (1) Personal
Representative, (2) Executor of Will, or (3)
Administrator of Estate. Note: You must mail
original Order or Letter of Administration.
OR
If you were unable to obtain an appointment as one
of the above, any documentation demonstrating that
you could not get the necessary appointment (see
instructions for more information) and either:
1) Submit a copy of the Decedent's will
and copies of relevant filings you have
made to probate the will
OR
2) If there is no will, submit:
Proof of your relationship to the
Decedent (such as birth certificate(s)
and/or marriage certificate) and
Proof that you are the first person in line
of succession under the laws of intestacy
in the Decedent's domicile.
7109100514
42
Submission
Complete
For Internal
Use Only
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part I.E. Information about the Decedent's
Participation in Lawsuits Related to September 11,
2001 (If Applicable)
If the lawsuit has been withdrawn, please submit the
notice or motion of withdrawal. That withdrawal must be
filed on the relevant court docket on or before January 2,
2012. Please note that you must also submit the final
order of the court confirming withdrawal in order for the
VCF to issue payment on your claim if you are
determined to be eligible.
If the lawsuit has been settled and released, please
submit a copy of the settlement agreement and release.
The documents you submit must show the date of the
settlement and release, the total settlement amount, and
the medical condition that was approved for payment
under the settlement.
If the attorney of the Decedent or Decedent's
dependent, spouse or beneficiary signed and
submitted the release, you must also provide a
copy of the retainer agreement with the attorney
in the settled lawsuit as proof that the attorney
was authorized to sign the release.
If the lawsuit has been dismissed, please submit the
order of dismissal.
If Decedent or anyone on the Decedent's behalf has
filed a lawsuit or claim for compensation for the
claimed condition with any court or bankruptcy trust
for any respiratory injury or disease due to exposure
unrelated to September 11, 2001 (e.g., asbestos),
please submit information on the action or claim
(court/trust, year filed, docket number,
injury/disease claimed) and documentation of any
judgment, settlement or trust compensation.
7034448134
43
Submission
Complete
For Internal
Use Only
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part II. Information About The Decedent's Presence
at a 9/11 Crash Site Between September 11, 2001
and May 30, 2002
Please submit written proof showing the Decedent was present at the
site. Examples of acceptable proof include the following:
Responders
Employer records confirming employment with an organization or entity
that was responsible for rescue and recovery, clean up, transportation of
debris, and confirming that the Decedent was present at the site,
including an official personnel roster, site credentials or a pay stub; OR
Contemporaneous documentation of presence - such as orders,
instructions, confirmation of tasks performed, contemporaneous medical
records, or contemporaneous records of federal, state, city or local
government.
Presence Claimed Based on Residence
Proof of residence in the area during the relevant time period such as (i)
rent receipts, mortgage receipts, or utility bills and (ii) proof that the
Decedent was physically present at the residence at some point between
September 11, 2001 and May 30, 2002, which could include at least two
(2) sworn and notarized affidavits (or unsworn statements complying with
28 U.S.C. 1746) from co-habitants, landlords, doormen, or neighbors.
Presence Claimed Based on Non-Responder Work in NYC Exposure
Zone or at the Pentagon
Employment records documenting employment and presence in the NYC
Exposure Zone or at the Pentagon; OR
Contemporaneous documentation of presence - such as
contemporaneous medical records, or contemporaneous records of
federal, state, city or local government.
Presence Claimed Based on School/Care Facility Attendance
School or day care records confirming enrollment / attendance during the
period.
Presence in the NYC Exposure Zone in some other capacity
(e.g. as a visitor)
Contemporaneous documentation of presence - such as
contemporaneous medical records, or contemporaneous records of
federal, state, city or local government.
Note: At least two (2) sworn and notarized affidavits (or unsworn
statements complying with 28 U.S.C. 1746) regarding the presence of
the Decedent from persons who can attest to the Decedent's presence at
a 9/11 crash site will serve as acceptable proof only if other official or
"primary" forms of proof (such as those listed above) are not available
and the Fund determines that such affidavits are sufficiently reliable.
9469122003
44
Submission
Complete
For Internal
Use Only
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part III. Information About the Decedent's Death
Proof of death (e.g. original or certified copy of death
certificate) and any other documents showing Decedent's
cause of death
AND
For any claimed injuries or conditions that were certified for
treatment under the WTC Health Program after July 1, 2011:
The VCF may be able to obtain the necessary records
directly from the WTC Health Program. It is possible that
the VCF will need additional records and if so, the VCF
will notify you and provide instructions.
For any claimed injuries or conditions that were treated by
physicians or programs other than the WTC Health Program:
You will need to provide certified contemporaneous
medical records and documents created by or at the
direction of the medical professional(s) who provided the
medical care.
Decedent's private physician(s) will need to complete
certain medical history forms. The VCF will send the
appropriate forms to the physician(s) to complete. The
Decedent's physician may submit those forms directly to
the VCF at September 11th Victim Compensation Fund;
P.O. Box 34500; Washington, DC 20043. Once those
forms are submitted, you should update this document
checklist to confirm submission of those documents.
Note: The documentation should include proof of when each
injury or condition was first treated by a medical professional.
Other Documentation in Support of
Eligibility: Parts I-III (optional)
Other documentation you have included in support of
Parts I-III
Other (please describe)
Other (please describe)
6888106489
45
Submission
Complete
For Internal
Use Only
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part IV. Attestations and Certifications
Please print Part IV and Exhibits A-F of the claim form, sign where
appropriate, and mail all pages of the Part (including pages you do not
need to sign) to the VCF at September 11th Victim Compensation
Fund; P.O. Box 34500; Washington, DC 20043. You must mail pages
with your original signature (no copies), but you should keep a copy
for your own records. If possible, please also upload electronic copies
of the signed pages. This will allow the VCF to begin processing your
claim.
Part IV.A: Privacy Act Notice
Please sign this section.
Part IV.B: Certification of Dismissal of Lawsuit
Please initial in the applicable space
Part IV.C: Acknowledgment of Waiver of Rights
Please sign this section.
Part IV.D: Authorization for Release of Information
Please sign this section.
Part IV.E: Personal Representative's Acknowledgement of
Attorney's Compliance with Limitation on Attorney's Fees
(If Applicable)
Only complete this section if an attorney provided legal services in
connection with this claim.
Part IV.F: Authorization for Communication and Correspondence
(If Applicable)
Only complete this section if an attorney or someone else identified in
Part I.C is assisting in the submission of this claim and if you want the
VCF to communicate with this person about your claim.
Part IV.G: Certification of Accuracy of Information
Please sign this section.
Exhibits A - F
Exhibit A: Authorization for Release of Medical
Records
Please identify all doctors and health care providers who
were involved in diagnosing and treating the Decedent's
injury, as well as any other entities (e.g., insurance
companies, workers' compensation programs, pension
programs) that may have medical information relevant to
this claim.
Then complete your own contact information and sign
and date the signature page.
8392303312
46
Submission
Complete
For Internal
Use Only
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Exhibits A-F (continued)
Exhibit B1: Authorization for Release of Pension
Records and Health Information by New
York Individuals and Entities (If
Applicable)
You must complete this exhibit if the Decedent was
awarded a pension by one of the following New York
pension funds:
New York City Police Pension Fund (POLICE)
New York Fire Department Pension Fund (FIRE)
New York City Employees' Retirement System
(NYCERS)
Teachers' Retirement System of the City of New York
(TRS)
New York City Board of Education Retirement
System (BERS)
To complete this exhibit:
Complete the boxes at the top of the page
Check the appropriate box in Question #7
Check the "Other" box in Question #9(a)
In Question #9(b), initial in the appropriate place and
write the name of the pension
Complete Question #12 and Question #13
Sign and date the form
Exhibit B2: Authorization for Release of Health
Information by New York Individuals and
Entities (If Applicable)
You must complete a copy of this exhibit for any medical
provider you identified in Exhibit A that is located in New
York state. You must also complete a copy of this exhibit
for any other doctors, facilities, hospitals, entities or
individuals in New York state that have medical
information that is relevant to your claim. You should
complete a separate copy of this exhibit for each
individual and entity.
To complete this exhibit:
Complete the boxes at the top of the page
Write the name and address of the individual or entity
in Question #7
In Question #9(a), initial in the three spaces next to
"Alcohol/Drug Treatment," "Mental Health
Information" and "HIV-Related Information."
In Question #9(b), initial in the appropriate place and
write the name of the individual or entity
Complete Question #12 and Question #13
Sign and date the form
0194044215
47
Submission
Complete
For Internal
Use Only
Decedent's SSN or Nat'l ID #
-
-
OMB 1123-0012
Personal Representative's SSN or Nat'l ID #
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - DECEASED INDIVIDUALS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Exhibits A-F (continued)
Exhibit C: Attorney Certification of Compliance with
Provision on Limitation on Attorney's Fees
(if Decedent or Personal Representative is
represented by attorney)
This section must be completed by any attorney that is
charging for legal services provided in connection with
this claim. If an attorney has not assisted with this claim,
you do not need to complete this section. [Attorneys that
have provided pro bono assistance with this claim do not
need to complete this Exhibit]
Exhibit D: Attorney Request for Approval for Charge
of Non-Routine Expenses
This section should not be completed unless an attorney
that provided legal services in connection with this claim
seeks to charge the Decedent or Personal
Representative for non-routine expenses. If the attorney
seeks non-routine expenses, a statement explaining the
non-routine expenses and why they should be approved
should be submitted with this exhibit.
Exhibit E: Notice of Filing Claim
You must complete and send a copy of this exhibit to all
of the following:
The immediate family of the Decedent (including, but
not limited to, the spouse, former spouse(s), children
other, depenpendents, siblings, and parents).
The Executor or Administrator and beneficiaries of the
Decedent's will and life insurance policies.
Any other person who may reasonably be expected to
assert an interest in an award or to have a cause or
action to recover damages relating to the wrongful
death of the Decedent.
Exhibit F: Notice of Filing Claim
You must complete this exhibit to identify for the VCF all
individuals to which you have sent a copy of Exhibit E.
0019191360
48
Submission
Complete
For Internal
Use Only
| File Type | application/pdf |
| Author | woody.bailey |
| File Modified | 2011-10-27 |
| File Created | 2011-10-27 |