Application For Filing A Claim For Compensation For Victims Of The 1924 (Page 2 of 4) in pdf

Application For Filing A Claim For Compensation For Victims Of The 1924 Page 2

Page 2 of

Section I: Claimant Information (please print)

Claimant’s Current Name ____________________________________________________________________

First, Middle, Last

Name at Time of Sterilization ________________________________________________________________

First, Middle, Last

If Claimant’s name at time of sterilization was different from current name, attach

documentation of name change (e.g., marriage certificate or other documentation).

If the Claimant died on or after February 1, 2015, attach a certified copy of a state

issued death certificate

Claimants Date of Birth __________/___________/___________

Month

Day

Year

Proof of Identity:

(Check at least one and attach a copy of the document)

___ State issued driver’s license

___ State issued picture identification card

___ United States passport

___ Foreign passport with Visa, I-94 or I-94W with picture

___ United States military card, active or retired member

Current Mailing Address______________________________________________________________________

City, State, Zip__________________________________________________________________________________

Phone (_____) ______________________________ Email______________________________________________

Section II: Documentation of Sterilization Procedure

Facility where Claimant was a patient when sterilization was performed

(check one)

___ Eastern State Hospital

___ Western State Hospital

___ Central State Hospital

___ Southwestern Mental Health Institute (Southwestern State Hospital)

___ Central Virginia Training Center (State Colony for Epileptics and Feeble-Minded)

Application For Filing A Claim For Compensation For Victims Of The 1924 Page 2