This field is hidden when viewing the formAgentThis field is hidden when viewing the formCall Center Entry IdThis field is hidden when viewing the formhidden last name*This field is hidden when viewing the formUTM CampaignThis field is hidden when viewing the formUTM SourceThis field is hidden when viewing the formUTM MediumThis field is hidden when viewing the formUTM ContentThis field is hidden when viewing the formUTM TermsThis field is hidden when viewing the formGCLIDThis field is hidden when viewing the formFBCLID CLAIM FORM If you were detained by the New York City Department of Correction beyond your scheduled release date between April 1, 1997 and December 21, 2012, based solely on a detainer issued by U.S. Immigration and Customs Enforcement you may submit a Claim Form for payment. Fill out and submit the Claim Form on this page. Claim Forms must be sent by May 15, 2025. Please call 1-800-479-0810 if you have questions or require assistance. Please complete the Claimant Identification section with your contact information because we may need to speak with you to arrange payment by check or wire. CLAIMANT IDENTIFICATION Claimant ID:*How did you hear about this Settlement?** Pick an Option **FacebookTwitterInstagramTVRadioInternet AdBus Shelter AdOtherOtherNAME:* First Name Middle Name Last Name/Surname/Family Name NAME:* First Name Middle Name Last Name/Surname/Family Name MAILING ADDRESS (include apartment, unit, suite, or post office box as applicable) Street Address City State / Province / Region Zip Code/Country Code (if known) AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone or Mobile Number (including area code or country/city code)Telephone or Mobile Number (including area code or country or city code)*Enter SMS Verification Code*Is Mobile Affiliated with WhatsApp? Yes No EMAIL ADDRESS: This field is hidden when viewing the formDate of Birth (Month/Date/Year)Birth DateMonth*** Select a Month **JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay*** Select a Day **12345678910111213141516171819202122232425262728293031Year*Social Security Number or ITIN (if available)New York State ID Number (NYSID) (if known)NYSID number: this is the number assigned to people once they enter the custody of Department of Corrections– not to be confused with the number on your NYS license, permit card, or identification card). TAX IDENTIFICATION NUMBER A Social Security Number (SSN) or I-TIN is not required for payment. If you do not provide your SSN or I-TIN, your claim will be processed and the administrator is required by law to withhold a percentage of your payment for back-up withholding. To avoid back-up withholding, please provide your SSN or I-TIN in the Claimant Identification Section. The Settlement Administrator cannot provide tax advice. Your payment will be reported to the IRS. ACKNOWLEDGEMENT AND SIGNATURE Filed OBO of Decedent CHECK HERE if the Class Member is deceased and you are filing on his or her behalf. You must send a copy of a court order appointing you administrator or legal representative of the Class Member’s estate to file on his behalf. Printed Name of legal representative*DECEASED DOCUMENTATION* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB, Max. files: 10. declare that the above information is true and correct.* By submitting this Claim Form, I declare that the above information is true and correct. By signing this Claim Form, I declare that the above information is true and correct. Date* MM slash DD slash YYYY This field is hidden when viewing the formTesting Verification Code*Unique IDClaimFormNoCommentsThis field is for validation purposes and should be left unchanged.