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

Application For Filing A Claim For Compensation For Victims Of The 1924 Page 4

Page 4 of

Phone (_____) _______________________________ Email_____________________________________________

Relationship to Claimant ______________________________________________________________________

Section IV: Certification

I hereby certify the authenticity of the documents referenced in and submitted as evidence

for compensation to victims of sterilization. I also hereby acknowledge that I have read the

instructions and understand that this application will not be accepted for evaluation or for

the award of compensation if it is determined that it has not been prepared in compliance

with the instructions.

____________________________________________________________________________ Date _____________________

Signature of Claimant or Claimant’s Legally Authorized Representative

Section V: Acknowledgment of Individual

Commonwealth 0f Virginia.

County/City of _____________________________________________________________

The foregoing instrument was acknowledged before me this ________ day of _______, 20_______,

by _____________________________________________________________________________________________________

Name of person seeking acknowledgement

Notary Public’s Signature: __________________________________________________________________________

Notary’s Registration Number: _____________________________________________________________________

My Commission Expires: ____________________________________________________________________________

Notary Seal

Application For Filing A Claim For Compensation For Victims Of The 1924 Page 4