Notarized Authorization Form

Form Description

The Notarized Authorization is essential to the claims process. Without a properly notarized authorization, the Virginia Victims Fund cannot begin to process a victim’s Claim Form for benefits. The Notarized Authorization allows VVF to collect documents on the victim’s behalf to help satisfy claim requirements. It also includes an acknowledgement of the terms of use, including an agreement for VVF to pay providers on the victim’s behalf, an acknowledgement that the victim will receive benefits from the fund in place of direct restitution payments from the offender, and an acknowledgement that if the victim receives benefits for expenses that VVF has paid from any other source, they must immediately repay the award. An oath that the information included in the Claim Form is correct and truthful is also included.

Form Instructions

The name of the victim of the crime must appear in the line under the heading “Authorization”. The claimant (the person claiming benefits from VVF) must both print and sign their name in the indicated spaces. Competent adults are their own claimants, but minor children, incapacitated adults, and deceased victims will have another responsible party act as their claimant. A registered notary must sign the Notarized Authorization, including the date and place sworn, the expiration date of their notary commission, and their notary number.

Fax or mail to:
Virginia Victims Fund
P.O. Box 26927
Richmond, VA 23261
Fax: 804-823-6905