VOCA Rights Waiver Form

VOCA RIGHTS WAIVER FORM

This VOCA Rights Waiver Agreement is made on this day: of , by and between Claimant Name: (Claimant) and Program/Agency Name: (Agency).

RECITALS

WHEREAS, Claimant asserts that Claimant is a victim of criminal conduct and seeks financial assistance or related benefits administered pursuant to the Victims of Crime Act and related victim compensation or assistance programs ("VOCA benefits");

WHEREAS, Agency provides advocacy, assistance, and administrative support in preparing and pursuing VOCA benefits and, in furtherance of such assistance, requires certain rights and permissions from Claimant to obtain records, prepare claims, and communicate with third parties; and

WHEREAS, Claimant wishes to authorize and waive certain rights to enable Agency to act on Claimant's behalf in connection with the pursuit of VOCA benefits as set forth below.

NOW THEREFORE, in consideration of the promises and mutual covenants contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following definitions apply: "VOCA benefits" means financial compensation, counseling reimbursement, and other program benefits administered under laws and regulations governing victim compensation and assistance; "Confidential Records" means medical, mental health, employment, education, law enforcement, investigative, and other records relating to the Claimant; and "Authorized Parties" means Agency representatives, program administrators, and governmental personnel with responsibility for adjudication of VOCA benefits.

2. SCOPE OF WAIVER

Claimant knowingly, voluntarily, and expressly waives the following rights to the limited extent necessary for Agency to prepare, file, prosecute, and administer a VOCA claim on Claimant's behalf. Claimant acknowledges that this Waiver is limited in scope and does not waive rights unrelated to pursuit of VOCA benefits:

Right to receive certain notifications related to release of Claimant records to Agency when required for claim processing
Right to object to release of medical, mental health, employment, education, and law enforcement records to Authorized Parties for the VOCA claim
Right to withhold consent for disclosure of information to third parties involved in claim adjudication
Other rights as specified:

3. AUTHORIZATION TO RELEASE INFORMATION

Claimant authorizes all persons and entities having records or knowledge of Claimant's claim to release to Agency and Authorized Parties copies of Claimant's medical, counseling, psychological, employment, education, law enforcement, investigatory, and other records relevant to the VOCA claim. This authorization includes release of records protected by applicable privacy laws to the extent permitted by law for claim adjudication.

This authorization shall remain effective for a period of unless earlier revoked in writing in accordance with Section 9.

4. ACKNOWLEDGMENT OF VOLUNTARINESS AND COUNSEL

Claimant acknowledges that Claimant has read this Agreement, that Claimant understands its nature and consequences, that Claimant has had the opportunity to seek independent legal advice prior to signing, and that Claimant signs this Agreement voluntarily and without coercion. Claimant further acknowledges that Claimant retains the right to seek legal advice after executing this Agreement and that such advice will not invalidate this Waiver except as provided by applicable law.

5. LIMITATIONS, REVOCATION, AND EFFECT

Claimant understands that this Waiver is limited to disclosures and actions necessary to pursue VOCA benefits and does not authorize Agency to take actions beyond those necessary for claim preparation and administration. Claimant may revoke this Waiver only by providing written notice to Agency at the Notices address below; revocation shall not affect actions taken by Agency prior to receipt of such written revocation.

Waiver remains in effect until:

6. CONFIDENTIALITY AND RECORDS HANDLING

Agency agrees to maintain reasonable administrative, technical and physical safeguards to protect Confidential Records and to use such records only for purposes authorized by this Agreement or as required by law. Agency may retain copies of records in client files and may disclose to Authorized Parties only as necessary for the VOCA claim.

7. INDEMNIFICATION

Claimant agrees to indemnify and hold harmless Agency, its officers, employees, and agents from and against any claims, liabilities, damages, or expenses (including reasonable attorneys' fees) arising out of Claimant's misrepresentation of material facts, any false statements contained in Claimant's application, or Claimant's breach of this Agreement. This indemnity does not extend to liability arising from Agency's gross negligence or willful misconduct.

8. NOTICES

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to choice-of-law principles. This Agreement constitutes the entire agreement between the parties regarding the subject matter hereof and supersedes all prior written or oral agreements. If any provision of this Agreement is held invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect.

10. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment or modification of this Agreement must be in writing and signed by both parties. No waiver of any provision shall be effective unless in writing signed by the party waiving compliance. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. CERTIFICATION

By signing below, Claimant certifies that Claimant is the individual identified herein, that all information provided to Agency is true and correct to the best of Claimant's knowledge, and that Claimant is executing this Waiver knowingly and voluntarily.

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