International Terrorism Victim Expense Reimbursement Program Application

OMB Number 1121-XXXX

Expiration: XX/XX/XX

ITVERP Application Instructions

Paperwork Reduction Act Notice: Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We attempt to create forms and instructions that are accurate, easily understood, and that impose the least possible burden on you to provide us with information. The estimated time to complete and file this application is 45 minutes per application. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office for Victims of Crime (OVC), U.S. Department of Justice, 810 7th Street, NW, Washington, D.C., 20531.

General Instructions:

1. Please type or print clearly on the application.

2. If you need more space on the application, please use the Supplemental Sheets or attach additional paper. Provide information for each category identified on the application from the section you are supplementing with additional paper.

3. Make certain you read, sign, and date the Authorization, Consents, and Certifications section (Section I) before sending your application, as no application for expense reimbursement will be processed without an original claimant signature and date.

4. If available, attach original receipts for those qualified expenses for which itemized expense reimbursement is being requested. If for some reason original receipts are unavailable, please submit photocopies of all documentation in lieu of original receipts, and attach a written affidavit attesting that the claimant/victim incurred expenses for which receipts are not available, and explain why original receipts are not available.

5. If your mailing address or other contact information changes, it is important that you notify ITVERP of such changes as soon as possible, or provide a permanent or alternative address.

6. Eligible victims of international terrorism may be reimbursed for expenses associated with their victimization. The five major categories of expenses covered by the ITVERP are the following:

• Medical Expenses (including Dental and Rehabilitation Costs)

• Mental Health Services

• Funeral and Burial Expenses

• Property Loss, Repair, Replacement

• Miscellaneous Expenses (e.g., temporary lodging, local transportation, telephone costs, emergency travel)

1. Should you have questions completing the application, or with regard to the five expense categories, please contact ITVERP at 202–307–5983 or visit the OVC Web site at www.ojp.usdoj.gov/ovc.

Delivery Instructions for Your Application Packet: The preferred methods of delivery for your application, attachments, and receipts include either hand-delivery or private carrier (e.g., UPS, FedEx). Applicants may use the U.S. Postal Service (USPS), but the Federal Government experiences long processing delays with USPS mail, that will significantly delay the processing of your application. Further, because the program regulations require original documentation and an original signature on the application, application packets cannot be sent through the Internet or by facsimile. (The application, however, can be accessed via the Internet, downloaded, and printed for your use.) Deliver the original application, any attachments, and all receipts to the following address:

Office for Victims of Crime

U.S. Department of Justice

810 7th Street, NW.

Washington, D.C. 20531

Specific Instructions for the Application:

Section A: Application Type (All Applicants)

Make only one selection for the type of application you are filing. Most, if not all, applicants will be filing an itemized application, that allows applicants to itemize their expenses.

An interim emergency payment application may be made to assist claimants with immediate expenses if the Director determines that such payment is necessary to avoid or mitigate substantial hardship that may result from delaying expense reimbursement until complete and final consideration of an application. The claimant may apply for an interim emergency payment to cover immediate expenses such as medical expenses, funeral and burial expenses, short-term lodging, and emergency transportation. The amount of an interim emergency payment shall be determined on a case-by-case basis, and shall be deducted from the final award amount. Please note: Once an interim emergency payment application has been completed, received by ITVERP, and assigned an original claim number, and if the claimant is ever in need of future expense reimbursement, the claimant must then file a supplemental application (as described below), rather than an itemized application.

Some individuals may need to file a supplemental application if additional costs arise, or if original costs were initially excluded from the first application. If the claimant is filing a supplemental application, it is imperative that you provide the original claim number so that your supplemental application can be matched up to your initial application.

Please check the appropriate box identifying the type of application being submitted (i.e., itemized application, interim emergency payment application, or supplemental application).

Section B: Victim Information (All Applicants)

Most of the information requested in this section is self-explanatory, but a few items may need further clarification.

1. SSN/EIN/Other Identification Number: This is asking either for the victim’s Social Security number, Employee Identification Number, or other identification number (e.g., embassy employee identification number, national identification card number).

2. Victim Status: The victim may be a U.S. national or a U.S. government employee (or both).

3. If the victim is a U.S. government employee, please indicate whether the victim is a foreign service national, foreign service officer, civil servant, contractor, or other specified type of U.S. government employee.

4. Claimant Eligibility: Claimant may include the victim, a spouse, child, parent, legal guardian, dependent, or other personal representative legally designated by one of the preceding to submit an application for expense reimbursement on behalf of an eligible victim. Applicant should mark only one of the choices.

Section C: Claimant Information

This section should be completed only if you are filing this application on behalf of a victim. If the victim and the claimant are the same person, applicant may proceed directly to Section D. The information requested in this section is self-explanatory.

Section D: Crime Information (All Applicants)

Please provide the requested information regarding the act of international terrorism. The requested information is self-explanatory. For purposes of clarification, a “lead investigative agency” is the law enforcement agency that has taken primary control over the investigation of the act of international terrorism. This may not always be a U.S.-based law enforcement agency. For example, the lead investigative agency of the terrorist attack on flight Pan Am 103 was the Dumfries and Galloway Constabulary of Scotland.

Section E: Expenses

1. Check all applicable expenses for which you are seeking an interim emergency payment (in U.S. dollar amounts), including any associated travel expenses for the various categories. Also note the total reimbursement requested (also in U.S. dollar amounts).

2. Check whether you have any other sources of reimbursement that may cover your expenses, and, if you do, specify what those other sources of reimbursement are.

3. Finally, check whether you anticipate incurring additional costs related to this act of terrorism that will result in a claim for additional assistance from OVC.

Section F: Collateral Sources (All Applicants)

In this section, please acknowledge any and all sources of financial support that have either been applied for or received in relation to this act of international terrorism.

1. Mark any and all applicable categories of financial support to which you have applied or from which you have already received funds.

2. If there is a financial source to which you have applied or received funds from, and it is not in the list, please mark “Other” and briefly note the source.

3. Indicate whether you have previously received any funds from the OVC or its Contractor. If so, please report the dollar amount and what the funds were for.

4. For each type of financial support to which you have applied or from which you have already received funds, please note the source, policy number (if applicable), name of company (if applicable) the company’s complete telephone and fax numbers (including country codes and area codes), the e-mail address (optional), the name of the individual reimbursed, and the Social Security number (if applicable) of the individual reimbursed. If more than one individual, use the attached Supplemental Sheet (Section H) to provide information on all sources of coverage.

5. Mark the Status of Application. If the application for an insurance payment, benefit, or compensation has been approved, please note the actual dollar amount in U.S. Dollars (USD) paid out or received.

Section G: Service Provider Information (Itemized and Supplemental Applicants Only):

Please provide information on the person(s) and organization(s) that provided services to the victim related to the act of international terrorism. If necessary, continue on a separate sheet of paper, and include all documentation of services received and related costs. The information requested in this section is self-explanatory.

Section H: Authorization, Consents, and Certifications (All Applicants)

Claimant must carefully read, sign, and date this section. No application for expense reimbursement will be processed without an original claimant signature and date. In addition, if a representative completed the application, either in whole or in part, or any other individual assisted in the preparation of this application, that person must also read, sign, and date this section.

Final Note:

All authorized payments will be made in USD, via electronic funds transfer or by check. Payments made by check will be mailed or delivered via courier service to the claimant’s last known address, unless otherwise requested by the claimant and approved by the Director of OVC.

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