PHYSICAL INJURY

You will eventually need to prove in a court of law your injury through documentation and from the statement of healthcare professionals to receive compensation. You will not need to prove your physical injury here. This form is for those that were not simply inconvenienced by Ohio's emergency public health orders. This form is for:

Those that endured pain and suffering due to not having timely access to healthcare. Where your access to healthcare was hindered by emergency public health orders.
Those survivors that are executors of an estate of someone that died due to not having timely access to healthcare that was reasonably caused by Ohio's emergency public health orders.
Those that conditions worsened and resulted in new conditions forming due to not having timely access to healthcare that was reasonably caused by Ohio's emergency public health orders.

Physical Injury

A Petition of affidavit is not an affidavit. It is a petition that if called upon - you will submit a notarized affidavit.

**You must be a United States Citizen
**You must be registered to vote for positive identification

First Name*

M.I.

Last Name*

Address 1*

Address 2*

City*

State*

Zip*

Phone Number*

Email address*

County you are registered to vote in*

Type

For me

Executor

Name of deceased

Relative

Last Residence

D-Address 2

D-City*

D-State*

D-Zip*

Upload a picture of the decedent's death certificate

Drop files here or click to select

Describe your Physical Injury or the Decedent's Injury*

Minimum amount you believe you should be compensated?*

Maximum amount you believe you should be compensated?*

Upload a prepared Affidavit now, if you have one. As a .pdf or .docx format.

Drop files here or click to select

Date*

Time*