As used in this Part and for the purposes of Executive Law, article 22, in addition to the definitions contained in Executive Law, article 22:
Representative's Authorization by Claimant
Pursuant to New York State Executive Law, § 633 and Public Officers Law § 96, I:
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Name of Claimant
(Please print)
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Claim Number
hereby authorize:
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Name of Representative
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Address of Representative
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Phone Number of Representative
to act as my representative in the above mentioned claim. This authorization is to allow the Office of Victim Services to share my information and records compiled for this claim with the above authorized representative. This authorization shall be valid until revoked by me in writing.
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Signature of Claimant
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Date
State of New York | )) ss.::: |
County of | |
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On the ________ day of ________ in the year ________ before me, the undersigned, 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 he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.
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NOTARY PUBLIC
Family members who perform such services shall be reimbursed at a rate no greater than the current State minimum wage for up to 40 hours per week.
N.Y. Comp. Codes R. & Regs. Tit. 9 § 525.3