Restitution Claim Form - New York Legal Assistance Group
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1RESTITUTION CLAIM FORM - For IIF/IPA Immigrant Restitution Fund
Deadline for Filing Restitution Claim Form: October 23, 2014
This Restitution Claim Form must be electronically submitted or postmarked no later than October, 23, 2014. Claims not
filed by the above deadline will not be reviewed by the Administrator.
NOTE: This form will not be accepted unless each field marked with an asterisk (*) has been completed.
Providing false, misleading or incomplete information on this form could jeopardize your right to restitution. This form
and information or documents you submit will not be shared with any other government entities.
The Claims Administrator will verify that you received legal services from IIF/IPA based on the information you provide
in this form. The verification will include conducting a search of IIF/IPA case-files by name, file number, and other
identifying information. If the Claims Administrator is unable to verify that you received legal services, the Claims
Administrator may request additional information from you to evaluate your eligibility.
This claim form can be submitted by Mail (Send to: NYLAG, Attn: Restitution Fund, 7 Hanover Square, 18th Floor,
New York, NY 10004), Email , or Fax (212-714-7400). Please call the Fund hotline (212-514-4265)
with any questions or concerns. Upon receipt of the form, NYLAG will review the form. Once all claim forms have been
reviewed, those applicants deemed eligible will be contacted and issued a restitution payment from the Fund.
PART I – PERSONAL INFORMATION
First Name *
Phone Number * (
)
–
Last Name *
Date of Birth *
/
/
(mm/dd/yyyy)
(Optional) Email Address:
Current Address *
Street Address
Apt., Suite, Bldg. (optional)
City
State
Zip Code
Country
PART II – CASE INFORMATION
What was the legal issue IIF/IPA agreed to assist you with?*
What was your address when you last received legal services from IIF/IPA?*
(Optional) What was your IIF/IPA case or file number?
(Optional) What family members also received legal services from IIF/IPA?
(Optional) What was or is your Alien Registration Number?
(Optional) In addition to this form, you may submit up to three documents that show you received legal services from
IIF/IPA. Examples include but are not limited to: IIF/IPA billing statements, IIF/IPA payment confirmation receipts, or
other documents that establish payment to IIF/IPA for legal services.
PART III – IDENTIFICATION DOCUMENT*
To be eligible for compensation, you must submit at least one copy of an identification document with this form. Ac-
ceptable examples include: a U.S. or other country-issued passport, national I.D. card, consular I.D., driver’s license,
permanent resident card, birth certificate, school I.D., employee I.D., or trade certificate.*
I declare under penalty of perjury that the information provided in this claim is true and correct to the best of my
knowledge.*
Signature
Date
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