Application For Filing A Claim For Compensation For Victims Of The 1924 (Page 3 of 4) in pdf

Application For Filing A Claim For Compensation For Victims Of The 1924 Page 3

Page 3 of

Date and year of sterilization

________________________________________________

(please print)

Documentation that the sterilization was performed under the authority of the 1924

Virginia Eugenical Sterilization Act

(check at least one of the following and attach a

copy of the documentation).

___ Letter notifying a parent, guardian or lawfully authorized representative of the

claimant that the sterilization procedure was performed.

___ Progress notes from the claimants hospital record documenting that the

sterilization procedure was performed.

___ Case summary from the claimant’s hospital record documenting that the

sterilization procedure was performed.

___ Physician’s order for sterilization from the claimant’s hospital record.

___ Operative record of sterilization from the claimant’s hospital record.

___ Sterilization record summary from the claimant’s hospital record.

___ Nurses notes documenting post-operative care provided to the individual

claimant, following the sterilization.

___ Other documents that show proof of sterilization having been performed under

the authority of the 1924 Virginia Eugenical Sterilization Act.

Section III: Legally Authorized Representative Information (if

applicable)

If the person completing the application is doing so on behalf of the Claimant, check

one of the following and attach a copy of documentation to prove the legal authority

to act on behalf of the Claimant.

___ I am permitted by law or regulation to act on behalf of the Claimant; or

___ I am a personal representative of the estate of the Claimant, as defined in Virginia

Code § 64.2-100, of a Claimant who died on or after February 1, 2015.

Identifying information of the legally authorized representative of the Claimant

(Print)

First, Middle, Last Name: ____________________________________________________________________

Mailing Address________________________________________________________________________________

City, State, Zip__________________________________________________________________________________

Application For Filing A Claim For Compensation For Victims Of The 1924 Page 3