AURORA VICTIM RELIEF FUND PROGRAM CLAIM FORM FOR PHYSICAL INJURY DEADLINE FOR SUBMISSION OF THIS FORM

M IS NOVEMBER 1, 2012

To assist us in responding to your claim as soon as possible, please help us by completing the information requested in the form below. If you need assistance in completing this form, please call or email Phyllis Hanfling at Phyllis.hanfling@state.co.us (303) 866-6395
SECTION 1. VICTIM INFORMATION
First Name: SSN Number: Street Address 1 Street Address 2 City Telephone Number (Day) State Zip Code Telephone Number (Evening/Cell) MI: / / Last Name:

SECTION 2. VICTIMS CIRCUMSTANCES ON JULY 20, 2012

Present in Century 16 Multiplex Theater in Theater 8 or 9 Present in Century 16 Multiplex Theater Complex

SECTION 3. INFORMATION REGARDING THE VICTIMS PHYSICAL INJURIES (complete this Section if you were physically injured on July 20, 2012)
Were you hospitalized overnight as a result of your injuries sustained on 7/20/12? Yes No Enter the total number of days and nights of hospitalization during the period between 7/20/12 and October 15, 2012? ________________

SECTION 4. MEDICAL INFORMATION

Please provide a brief description of your injuries:

Did your injuries result in permanent paralysis or brain injury? I have attached documentation to verify the length of my hospitalization (for example, a letter from the hospital or health care provider).

Yes

No

Yes

No

SECTION 5. COUNSELING SERVICES

I am interested in finding out about counseling services offered in my area. Please contact the Colorado Organization for Victim Assistance. (Contact COVA at (303) 861-1160 or 1(800) 261-2682.)

Yes

No

SECTION 6.

PAYMENT

Please mail a check to Claimant at the address shown in Section 1 above. Please provide your telephone contact information below: Telephone No.(Day): Telephone No. (Evening/Cell):

SECTION 7.

SIGNATURE and NOTARIZATION

I hereby certify that the information provided in this application is true and accurate to the best of my knowledge. Signature of Claimant on this Claim Form does not Constitute a Waiver of any Legal Rights.

SIGNATURE OF VICTIM (Required):

DATE: County of:

Required: Notary Statement

State of:

The foregoing instrument was subscribed and sworn before me this ___ day of __________, 2012, by ________________________________________________________________________________________________. My Commission Expires: Affix Notary Seal Here:

SIGNATURE OF NOTARY: (Required)

DATE:

Please Return Completed Claim Form via U.S mail to: Aurora Victim Relief Fund Program Kenneth R. Feinberg, Fund Administrator c/o Office of the Governor of the State of Colorado 136 State Capitol Denver, CO 80203 Or Email: c/o Phyllis.hanfling@state.co.us