File 600.9.2 ATTACHMENT TO FTCA CLAIM APPROVAL LETTER

ATTACHMENT TO FTCA CLAIM SETTLEMENT LETTER
You must ACCEPT or REJECT this offer, SIGN this document, and RETURN it to TSA.

o

I ACCEPT this offer.

Payee Social Security Number or other taxpayer identification number: _ _ _ _ _ _ _ __
Payee Name or Company: __________________________
Address (PO Boxes are not accepted): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
City: _ _ _ _ _ _ _ _ _----'State: _ __ Zip: _ _ _ _ _ Country: _ _ _ _ _ __
NOTICE: If you choose this option, you are accepting the offered payment in full satisfaction and release of aU
claims relating to the incident from which your claim arose. If your claim is governed by California law, you
waive the protections of Calif. Civ. Code § 1542. I and my guardians, heirs, executors, administrators, and assigns ("I") agree to and
do accept this settlement in full settlement and satisfaction and release of any and all claims, demands, rights, and causes of action of any kind, whether
known or unknown, including without limitation any claims for fees, costs, expenses, survival, or wrongful death, ariSing from any and all known or
unknown, foreseen or unforeseen bodily injuries, personal injuries, death, or damage to property, which I may have or hereafter acquire against the
United States of America, its agents, servants, or employees, on account of the subject matter of My administrative claim, or that relate or pertain to or
arise from, directly or indirectly, the subject matter of My administrative claim. I further agree to reimburse, indemnify, and hold harmless the United
States of America, its agents, servants, and employees, from and against any and all claims, demands, rights, and causes of action of any kind, whether
known or unknown. including without limitation claims for subrogation, indemnity, contribution, or lien of any kind, or for fees, costs, expenses, survival or
wrongful death that relate or pertain to or arise from, directly or indirectly, any act or omission that relates to the subject matter of My administrative claim.

Payment Method:

o I request a check mailed to the address above. (You will receive a check from the U.S. Treasury)
CJ

I request payment by electronic funds transfer into the following account: (Deposit will be
from the U.S. Treasury. Deposit code will show as USCG Treas or CGVA.) Option for U.S. bank
payments only - any errors or omissions in the banking information below may result in your payment being mailed to the above
address. Bank account must be in the claimant's (or guardian) name.

Payee Account Name:

U.S. Bank Name:

U.S. Routing Number/ABA Bank # (9 digits):

U.S. Bank Address:

Payee Account #:
Check One:
Checking Account

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~avings

Account

I REJECT the settlement offer, but request reevaluation of the offer.

I acknowledge that I am acting in my capacity as the claimant; as the claimant's duly authorized agent; or as the
claimant's legal representative.

Authorized Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Date: _ _ _ _ _ _ __

PRIVACY ACTSTATEMENT AND PAPERWORK REDUCTION ACT STATEMENT
AUTHORITY: 31 U.S.C. 3325(d); 31 U.S.C.3332. PRINCIPAL PURPOSE(S): This information will be used to remit payment of your claim. ROUTINE USE(S): The
information you provide, including your social security number, will be disclosed to the U.S. Treasury Department to determine whether you have any outstanding debts to
the government that should be paid from your settlement and may also be disclosed to other Federal agencies in order to process your claim, or for other routine uses listed
in the applicable system of records notices. DISCLOSURE: Voluntary; failure to furnish the requested information may result in a delay or denial of payment on your claim.
Failure to provide you SSN ot taxpayer identifying number may result in a delay of payment of your claim.
Paperwork Reduction Act Statement of Public Burden: TSA is collecting this information because a determination has been made regarding your tort claim against the
agency that payment is warranted; therefore TSA needs certain information to faCilitate payment. The public burden for this collection of information is estimated to be
approximately 30 minutes. This is a voluntary collection of information; however. failure to provide this information may delay or hinder the processing of your claim
payment. An agency may not conduct or sponsor, and persons are not required to respond to. a collection of information unless it displays a currently valid OMB control
number. The OMB control number assigned to this collection is 1652·0039, which expires 08/31/2009.

File 600.9.2
eMB 6-1-7