Section Jus 604.01 - Claim Application Form(a) Each claimant seeking compensation from the fund shall complete and submit a "New Hampshire Victim's Compensation Program Application Form," revised 8/23/19 and available from the unit.(b) In addition to submitting the "New Hampshire Victims' Compensation Program Form," the claimant shall provide: (1) Documentation of expenses for the compensation of expenses and losses being sought;(2) A certification, under the penalties of RSA 641:2, as to whether the expenses and losses listed have not, will not, and cannot be covered by any other resource, private or public assistance program, and if they might be, a full description of such resources;(3) Copies of all documentation of denials or applications made to other resources, private or public assistance programs for payment or compensation of expenses and losses listed;(4) A statement by the claimant acknowledging and agreeing that recovery of any expenses listed through legal action shall entitle the State of New Hampshire to seek compensation to the fund to the extent of any award of compensation made under this chapter; and(5) A certification, under the penalties of RSA 641:2, that the claimant has provided information on or with the application that is true, complete, and accurate to the best of the claimant's knowledge and belief.N.H. Admin. Code § Jus 604.01
#4864, eff 7-13-90; ss by #6052, eff 7-1-95, EXPIRED: 7-1-03
New. #9553, eff 9-25-09
Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12938, Effective 12/9/2019, Expires 12/9/2029.