National Financial Restitution Authority (NFRA)
Victim Compensation — Bank Transfer Form
Secure Bank Account Transfer Submission Form
Claimant Information
Full Name:
Address:
Case ID:
Date of Submission:
Email:
Phone:
Bank Account Money Transfer
Bank Name:
Account Holder Name:
Account Number:
Bank Routing Number:
Account Type:
--Select--
Checking
Savings
Attach Copy of ID Card:
Certification / Authorization:
I certify that the bank account information provided is accurate and authorize the National Financial Restitution Authority (NFRA) to deposit the approved compensation directly to this account.
Signature (type full name):
Date:
Supporting Documents (Optional)
Additional Documents:
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