AURORA VICTIM RELIEF FUND PROGRAM CLAIM FORM FOR DECEASED VICTIMS

DEADLINE FOR SUBMISSION OF THIS FORM 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: Street Address: City: Marital Status: No. of Children: State: Zip Code: / M.I.: / Last Name:

Single

Married

Divorced

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. CLAIMANT/REPRESENTATIVE INFORMATION Please provide the following information:

Relationship to Victim:

(Note: If the deceased individual was married at the time of death, the spouse must sign the claim form. If the victim was not married, the personal representative legally administering the estate must sign the claim form. If the victim was a minor, both parents must sign the claim form. If both signatures cannot be obtained, please explain why.)

Is Spouse the Claimant? First Name: SSN: Street Address: City: Telephone No. (Day): State: M.I.:

Yes Last Name:

No

Zip Code:

Telephone No. (Evening/Cell):

SECTION 4.

SUPPORTING DOCUMENTATION ATTACHED

Yes Yes Yes No No No

Proof of relationship to the Victim (such as birth certificate(s) and/or marriage certificate): Proof of appointment as Personal Representative, Executor or Administrator of the Estate: Copy of Death Certificate Attached:

SECTION 5.

COUNSELING
Yes No

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

SECTION 6.

PAYMENT
Please provide your

Please send a Check to the Claimant(s) at the address shown in Section 3 above. telephone contact information below: Telephone No. (Day): Telephone No. (Evening/Cell):

SECTION 7.

SIGNATURE and NOTARIZATION

SIGNATURE OF CLAIMANT No. 1

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 CLAIMANT: DATE: County of:

Notary Statement (Required)

State of:

The foregoing instrument was subscribed and sworn before me this ___ day of _________________, 2012, by _____________________________________________________________________________________________________.

My Commission Expires:

Affix Notary Seal Here DATE:

SIGNATURE OF NOTARY: (Required)

SIGNATURE OF CLAIMANT No. 2 (If applicable -- If Victim was a minor child, signatures of both Parents is Required)
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. (If the victim was a minor, both parents must sign the form below. If both signatures cannot be obtained, please explain why.) SIGNATURE OF CLAIMANT : DATE:

Notary Statement (Required)

State of: County of:

The foregoing instrument was subscribed and sworn before me this ___ day of _________________, 2012, by _____________________________________________________________________________________________________.

My Commission Expires:

Affix Notary Seal Here: DATE:

SIGNATURE OF NOTARY: (Required)

Return 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