EFTA01651839

KATHY HOCHUL Governor Director Office of Victim Services ELIZABETH CRONIN ESQ. AFFIDAVIT IN SUPPORT OF LATE FILING OF OVS CLAIM (TO BE COMPLETED BY CLAIMANT) NAME : CLAIM NO: DATE OF CRIME: LOCATION OF CRIME: DATE REPORTED TO POLICE: DATE CLAIM FILED WITH THE OVS: DATE YOU WERE INFORMED OF THE OFFICE OF VICTIM SERVICES: LIST THE FACTORS WHICH CAUSED THE DELAY IN FILING THE CLAIM BEYOND THE STATUTORY ONE YEAR FILING PERIOD: Signature of Claimant / / Date State of New York County of On this day of 20 , before me, the undersigned Notary Public in and for the State of personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that (s)he executed the same in his/her capacity and by his/her signature on the instrument (s)he executed the instrument. *I-55* Notary Public Seal/Stamp 4 An aw I Office of YORK Victim Services '822340' Alfred E. Smith State Office Building. 80 South Swan Street. Albany. NY 12210 EFTA01651839