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Exhibit B1

November 15, 2022
Resource type
Forms

The VCF does not accept electronic signatures. If you received this form electronically you must print the signature page and sign by hand.

Change Log:

October 2022: Updated form includes checkbox for NYSLRS.

November 15, 2022: updated to say “Victim’s SSN” instead of “Claimant’s SSN”, added medical records to 9(a).

Associated document(s)
Topics
Forms
Filing a Claim