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ACCESS HRA Resources
SNAP Benefits
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Repaying a Claim
Repaying a Lien
Repaying a SNAP Overpayment
Supplemental Needs Trust
Supportive Housing
Welfare Fraud Prevention
ACCESS HRA Resources
SNAP Benefits
Food Assistance
EBT Card Services
Rental Assistance
Adult Protective Services
Burial Assistance
Career Services
Cash Assistance
Child Support Services
Disability Access
Domestic and Gender-Based Violence Support
Energy Assistance
Fighting LGBTQ Food Insecurity
Health Assistance
HIV/AIDS Services
Homelessness Prevention
Immigrant Resources
Legal Assistance
LGBTQI
Long Term Care
Medicaid Provider Fraud
Other Services
Repaying a Claim
Repaying a Lien
Repaying a SNAP Overpayment
Supplemental Needs Trust
Supportive Housing
Welfare Fraud Prevention
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Please Complete the Form
*
- indicates required fields
Plaintiff Name:
*
Type of Lien:
*
Final
Updated
Last 4 Digits of Client SSN:
*
Date of Birth:
*
Settlement Amount:
Date of Incident:
*
NYC File Number (if action against NYC):
Settlement Date:
Index Number:
Case Number or CIN:
Specific Injury (E.G., Ankle Fracture):
*
Attorney Requesting Lien Represents:
*
Defendant
Plaintiff
Firm Name:
*
Firm Address:
*
Firm City:
*
Firm State:
*
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PE
PQ
PR
RI
SA
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Firm ZIP Code:
*
Attorney Name:
*
Attorney Email Address (e.g., test@example.com):
*
Attorney Phone:
*
Attorney Fax:
Submit