Notice Of Right To Request Waiver Of Deductible
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Notice Of Right To Request Waiver Of Deductible Form. This is a Connecticut form and can be use in Victim Services Statewide.
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Tags: Notice Of Right To Request Waiver Of Deductible, JD-VS-23, Connecticut Statewide, Victim Services
NOTICE OF RIGHT TO REQUEST
WAIVER OF DEDUCTIBLE
STATE OF CONNECTICUT
OFFICE OF VICTIM SERVICES
JUDICIAL BRANCH
www.jud.ct.gov/crimevictim
JD-VS-23 Rev. 6-08
C.G.S. ยง 54-210(a)(5)
Instructions
1. This form must be completed and signed for consideration of waiver.
2. Keep a copy for your records.
3. Forward original to the Office of Victim Services at the address shown below.
FROM: Office of Victim Services, 225 Spring Street, Fourth Floor, Wethersfield, CT 06109
Name of Victim
Claim Number
Name and Address of Claimant
Claims Examiner
State law requires that the Office of Victim Services (OVS) deduct $100 from every claim that receives compensation.
However, OVS may waive the deductible under Connecticut General Statutes Section 54-210 (a)(5).
Please check one box and indicate your relationship to the claimant:
(Self, mother, father, guardian, etc )
I am requesting a waiver of the $100 deductible, and I have written below why the deductible should be
waived.
I am not requesting a waiver of the $100 deductible (please note there will be a one time $100 deduction
from the amount of compensation awarded).
Request For Waiver of Deductible
I request that OVS waive the $100 deductible. I believe the $100 deductible should be waived because (you may attach
additional pages if necessary):
Print name:
Date signed:
Signed:
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