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For Waiver Ct Form
Wethersfield, CT 06109
Name of Victim
Claim Number
Name of claimant or person filing for claimant
Claims examiner
Check the appropriate box:
The claimant was a minor at the time of the criminal incident and the application was filed late through no fault of the
minor (Section 54-211(a)(3) of the Connecticut General Statutes).
The claimant was an adult at the time of the criminal incident and the application was filed late because the criminal
incident caused physical, emotional, or...
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