Annette Baca

Clean rooms do lobby work do laundry. I’m willing to learn whatever.

• This authorization is part of your application and must be completed and signed in order to process this application.
• BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING TERMS.
• Authorization for Release of Information: I hereby authorize any financial institution, social service agency, government agency, hospital, physician, mental health facility, counselor, psychologist, psychiatrist, employer, insurer or any other person with information relating to my financial, health or employment status to release information concerning this application for benefits to the employees of the New Mexico Crime Victims Reparation Commission, as needed to process this application. This information includes, but is not limited, to criminal, medical (relating to acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection or other sexually transmitted diseases, behavioral health services/psychiatric care, and treatment for alcohol, drug abuse test results), financial, and employment information.
• Subrogation Agreement: In accordance with NMSA 1978, Section 31-22-12 of the Crime Victims Reparation Act, I agree to notify the Commission before I file a lawsuit against another party as a result of this crime. If I recover or anticipate recovery, of any money at any time, by judgment, settlement, restitution, collateral source or any other income as a result of the incident that gave rise to this application, I agree to notify the Commission. I acknowledge that I may be responsible for repayment to the Commission for any and all amounts that the Commission has awarded to me. I hereby authorize the New Mexico Corrections Department to directly send to the Commission any restitution collected by the New Mexico Corrections Department from the offender related to the incident for which I received reparations.
• Authorization: I understand and agree that if false, misleading or intentionally incomplete information is provided, my application for compensation may be denied and I may be subject to criminal punishment, pursuant to NMSA 1978, Section 31-22-20 of the Crime Victims Reparation Act.
• VICTIM
• Printed Name: Date of Birth:
• Signature: Date:
• CLAIMANT
• Revised 4/2023