APPLICATION FOR WAIVER OF TWO YEAR FILING REQUIREMENT JD-VS-28 Rev. 8-11 C.G.S. § 54-211 STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov/crimevictim Instructions 1. 2. 3. 4. Print or type the information requested. The form must be signed by the person who signed the application for victim compensation. Keep a copy for your records. Mail to the address below or fax to 860-263-2780. Mail to: Office of Victim Services, 225 Spring Street, Fourth Floor, Wethersfield, CT 06109 Name of Victim Claim Number Name of claimant or person filing for claimant Claims examiner Check the appropriate box: The claimant was a minor at the time of the criminal incident and the application was filed late through no fault of the minor (Section 54-211(a)(3) of the Connecticut General Statutes). The claimant was an adult at the time of the criminal incident and the application was filed late because the criminal incident caused physical, emotional, or psychological injuries (Section 54-211(a)(2) of the Connecticut General Statutes). Describe the physical, emotional, or psychological injuries (you may attach more pages, if needed): Print name Signature (Parent or guardian if claimant is a minor) Date signed ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact the Office of Victim Services at the address shown above. American LegalNet, Inc. www.FormsWorkFlow.com