7/31/2019 Claim Form for Physical Injury

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AURORA VICTIM RELIEF FUND PROGRAM

CLAIM FORM FOR PHYSICAL INJURY

DEADLINE FOR SUBMISSION OF THIS FORM IS NOVEMBER 1, 2012

To assist us in respond ing to your cla im as soon a s possib le, p lea se help us by

com p leting the informa tion requested in the form below. If you need assistance in

com p leting this form, p lease call or email Phyllis Hanfling a t

Phyllis.hanfling @sta te .co.us

(303) 866-6395

SECTION 1. VICTIM INFORMATION

First Name: MI: Last Name:

SSN

Number:/ /

Stree t Ad dress 1

Stree t Ad dress 2

City Sta te Zip Code

Telephone Number (Day) Telephone Number (Evening/ Cell)

SECTION 2. VICTIMS CIRCUMSTANCES ON JULY 20, 2012

Presen t in Century 16 Multiplex Thea ter in Thea te r 8 or 9 Present in Cen tury 16 Multiplex Thea ter Complex

SECTION 3. INFORMATION REGARDING THE VICTIMS PHYSICAL INJURIES(c om plete this Sec tion if you w ere p hysically injured o n July 20, 2012)

Were you hospita lized overnight as a result o f your injuries susta ined on 7/20/ 12? Yes No

Enter the to tal numb er of da ys and nights of hosp italiza tion during the period between 7/20/12 and

Oc to ber 15, 2012? ________________

SECTION 4. MEDICAL INFORMATION

Please p rovide a brief d escrip tion o f your injuries:

Did your injuries result in permanent paralysis or b rain injury? Yes No

I have a ttac hed d oc umentation to verify

the leng th of my hospita liza tion (for

exam ple, a lette r from the hosp ital or hea lth

c are p rovider).

Yes No

7/31/2019 Claim Form for Physical Injury

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SECTION 5. COUNSELING SERVICES

I am interested in finding out ab ou t

c ounseling servic es offe red in my a rea.

Please c ontac t the Colorado Organization

for Victim Assistanc e. (Contac t COVA at

(303) 861-1160 or 1(800) 261-2682.)

Yes No

SECTION 6. PAYMENT

Please ma il a c hec k to Cla imant a t the add ress shown in Sec tion 1 ab ove . Please provide your

telephone conta c t informa tion below:

Telep hone No.(Day): Telep hone No. (Evening/ Ce ll):

SECTION 7. SIGNATURE and NOTARIZATION

I hereby certify that the information p rovided in this app lica tion is true and a c cura te to the b est of

my knowledge . Signa ture of Claimant o n this Claim Form does no t Constitute a Waiver of anyLeg a l Rights.

SIGNATURE OF VICTIM (Required): DATE:

Required: Notary Statem ent

Sta te of: Coun ty of:

The foregoing instrument was sub sc ribed and swo rn be fore me this ___ day of __________, 2012, by

________________________________________________________________________________________________.

My Co mmission Expires: Affix Nota ry Sea l Here:

SIGNATURE OF NOTARY: (Required) DATE:

Please Return Completed Claim Form via U.S mail to:

Aurora Victim Relief Fund ProgramKenneth R. Feinberg, Fund Administrator

c/o Office of the Governor of the State of Colorado

136 State CapitolDenver, CO 80203

Or

Email: c/o Phyllis.hanfling@state.co.us