Forms | Midpage

Collections
New Hampshire Code of Administrative Rules

Part 604

Forms

Jus 604.01Claim Application Form Jus 604.02Acknowledgment of Receipt of Claim and Request for More Information Letter Jus 604.03Vehicular Crimes Insurance Form Jus 604.04Law Enforcement Authority Verification Form Jus 604.05Verification of Employment and Lost Wages Form Jus 604.06Verification of Medical Expenses Form Jus 604.07Verification of Hospital Expenses Form Jus 604.08Mental Health Assessment and Treatment Plan Jus 604.09Verification of Funeral/Burial Expenses Form Jus 604.10Reminders and Warnings Jus 604.11Safety Plan Form: If a claimant seeks compensation for relocation assistance, the crisis center advocate assisting the victim shall complete and submit the “New Hampshire Victims’ Compensation Program Safety Plan Form,” as revised 8/23/19 Jus 604.1210-Day Emergency Funds Compensation Form