Form FCSC 1-09 FCSC 1-09 Statement of Claim

OMB Approval Number
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION

(FOR FCSC USE ONLY)
CLAIM NO. LIB II -

STATEMENT OF CLAIM
FOR FILING OF CLAIMS IN THE LIBYA CLAIMS PROGRAM PURSUANT TO THE LIBYAN
CLAIMS RESOLUTION ACT OF AUGUST 4, 2008, Pub. L. 110-301, THE CLAIMS SETTLEMENT
AGREEMENT BETWEEN THE UNITED STATES AND LIBYA DATED AUGUST 14, 2008,
EXECUTIVE ORDER 13477 OF OCTOBER 31, 2008, THE INTERNATIONAL CLAIMS SETTLEMENT
ACT OF 1949, AS AMENDED (22 U.S.C. 1621 et seq.) including 22 U.S.C. 1623(a)(1)(C), AND THE
LETTER OF REFERRAL FROM THE DEPARTMENT OF STATE DATED JANUARY 15, 2009.
NOTE: Please read the instructions carefully before completing this form. Additional pages may be appended to
this form as necesary.

CONTACT INFORMATION

1. CLAIMANT
Name of Claimant (Individual)
(Last)

(First)

(Middle)

Name of Claimant (Commercial)

(Street Address)
(State/Territory)

(City)

(Zip Code)

Home Phone

Work Phone
Email
Name of Injured Party if different from that of claimant
Relation to Injured Party
2. LEGAL REPRESENTATIVE
Name of Lawyer

(Last)

(Middle)

(First)

Name of Law Firm
(Street Address)
(City)
Phone

(State/Territory)

(Zip Code)

Fax

Email
Paperwork Reduction Act Statement: This information collection has been cleared under the Paperwork Reduction Act of 1995, 44 U.S.C. 3501 et seq. (Control
No.
). Under 44 U.S.C. 3506(c)(1)(B)(iii)(V), an agency may not conduct or sponsor, and a person may not be required to respond to, an information collection
request unless the information collection form bears a valid control number. Completion of this form is mandatory in order to obtain compensation (45 CFR509.2). The
estimated burden associated with this collection of information is 2.0 hours per individual respondent or recordkeeper and 40 hours per commercial respondent or
recordkeeper.

FCSC 1-09
January 2009

BASIC CLAIM INFORMATION
3. TYPE OF CLAIM
Please make one selection from the list of claim categories set forth below.
Category A - Claim for Hostage Taking and/or Unlawful Detention, complete only Sections 4, 5, 6, 7 and 14 below.
Category B - Claim for Intentional Infliction of Emotional Distress, complete only Sections 4, 5, 6, 8 and 14 below.
Category C - Claim for Special Circumstances in Cases of Wrongful Death, complete only Sections 4, 5, 6, 9 and 14 below.
Category D - Claim for Special Circumstances in Cases of Physical Injury, complete only Sections 4, 5, 6, 10 and 14 below.
Category E - Claim for Physical Injury or Wrongful Death (not previously filed in any U.S. court), complete only Sections 4, 5,
11 and 14 below.
Category F - Commercial Claims, complete only Sections 5, 6, 12 and 13 below.

4. U.S. CITIZENSHIP
Please state how and when U.S. nationality was acquired and provide supporting documentation:
By birth in the U.S. - provide the date and place of birth

By naturalization in the U.S. - provide the date and place of naturalization
Other - provide the date on which and the manner by which U.S. nationality was acquired (for example, by birth abroad to U.S.
parents, derivative naturalization, etc.)

5. PRIOR COMPENSATION
5.1 Has the claimant received any compensation with respect to the subject matter of this claim from any source including the United
States or a foreign government or agency thereof, or an insurance settlement, etc.? If the answer is "Yes", please provide the date of
receipt, source and amount of compensation, below.

5.2 Please provide any documents which were signed by the claimant in consideration of the receipt of the sums described above.
6. PENDING LITIGATION
6.1 Please identify the litigation or court case in which claimant was a party.
6.2 Please indicate the type(s) of injury pleaded in the Pending Litigation referenced above.
6.3 Please provide the Order of Dismissal with regard to the above identified litigation.

7. CATEGORY A - CLAIM FOR HOSTAGE TAKING AND/OR UNLAWFUL DETENTION
7.1 Did the claimant receive an award for physical injury from the FCSC
pursuant to the Department of State referral dated December 11, 2008?
7.2 Please briefly describe the incident giving rise to the claim.

7.3 Please provide evidence of the claimant's alleged hostage taking or unlawful detention.
8. CATEGORY B - CLAIM FOR INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS
8.1 Name of Deceased

8.2 Relationship to the Deceased

8.3 Please provide evidence of claimant's relationship to the deceased.
8.4 Did the claimant receive any compensation as part of the wrongful death claim paid by
the Department of State pursuant to the Settlement Agreement dated August 14, 2008?
8.5 Was the claimant eligible to recover for the wrongful death claim under the decedent's estate? (e.g. claimant
was a beneficiary under the decedent's will, by operation of intestate succession in the absence of a will, etc.)
8.6 Please attach documents relating to the distribution of the decedent's estate.
8.7 Has the claimant received or is the claimant, aside from this category, eligible for any
compensation directly from the Department of State or from the FCSC pursuant to
the Department of State's referrals dated December 11, 2008 and January 15, 2009?
9. CATEGORY C - CLAIM FOR SPECIAL CIRCUMSTANCES IN CASES OF WRONGFUL DEATH
9.1 Please describe the special circumstances of the claim.

9.2 Please attach any documents supporting the claim for special circumstances.

10. CATEGORY D - CLAIM FOR SPECIAL CIRCUMSTANCES IN CASES OF PHYSICAL INJURY
10.1 Did the claimant receive an award from the FCSC pursuant to the Department of State referral dated December 11, 2008?
10.1.1 If so, what Decision Number was assigned to the claim?
10.2 Please Describe the special circumstances of the physical injury on which the claim is based.

10.3 Please attach any documents supporting the claim for special circumstances.
11. CATEGORY E - CLAIM FOR PHYSICAL INJURY OR DEATH (not previously filed in any U.S. court)
11.1 Please identify the incident which caused the injury or wrongful death. (see covered incidents set out in the instructions)

11.2 Was the claimant a plaintiff in the Pending Litigation listed in the instructions?
11.3 Please provide evidence establishing that the injured party was present at the scene of the above incident.
11.4 If the claim is for physical injury, please briefly describe that injury.

11.5 Did the injured party receive medical treatment for the injuries
described above? If so, please attach supporting documentation.
11.6 For Claims of Wrongful Death please provide evidence that the cause of decedent's death was the above referrenced incident and
attach a copy of the death certificate.

12. CATEGORY F - COMMERCIAL CLAIMS
12.1 CITIZENSHIP OF THE CLAIMING ENTITY
12.1.1 Please indicate below the date and State of incorporation.

12.1.2 How many shares of capital stock of all classes or other beneficial
interest did the entity have outstanding on the date of loss?
12.1.3 How many shares of capital stock of all classes or other beneficial
interest were owned by U.S. nationals on the date of loss?
12.1.4 How many shares of capital stock of all classes or other beneficial
interest did the entity have outstanding on the date of filing?
12.1.5 How many shares of capital stock of all classes or other beneficial
interest were owned by U.S. nationals on the date of filing?
12.1.6 Please attach the Articles of Incorporation and a statement by the Secretary or other principal officer of the corporation (or other entity)
certifying all of the above.

12.2 CITIZENSHIP OF THE PREDECESSOR IN INTEREST TO THE CLAIM
12.2.1 Please indicate below the date and State of incorporation.

12.2.2 How many shares of capital stock of all classes or other beneficial
interest did the entity have outstanding on the date of loss?
12.2.3 How many shares of capital stock of all classes or other beneficial
interest were owned by U.S. nationals on the date of loss?
12.2.4 How many shares of capital stock of all classes or other beneficial interest
did the entity have outstanding on the date of transfer of the interest?
12.2.5 How many shares of capital stock of all classes or other beneficial interest
were owned by U.S. nationals on the date of transfer of the interest?
12.2.6 Please attach the Articles of Incorporation and a statement by the Secretary or other principal officer of the corporation (or other entity)
certifying all of the above.

12.3 DETAILS OF CLAIMED LOSS
12.3.1 Please indicate the total dollar amount being asserted in this claim $
12.3.2 Please indicate the basis for the above asserted value.

12.3.3 Excluding this claim, has the entity or any predecessor in interest received, or has any reason to expect to receive, any benefits,
pecuniary or otherwise, on account of the loss resulting from the incident which forms the basis of this claim? (If so, explain)

13. COMMERCIAL CLAIMANT CERTIFICATION
PENALTIES: Your attention is directed to the federal law on false statements, 18 U.S.C. section 1001, which provides:
[W]hoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United
States, knowingly and willfully–
(1) falsifies, conceals or covers up by any trick, scheme, or device a material fact;
(2) makes any false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially,
fictitious, or fraudulent statement or entry;
shall be fined under [Title 18, U.S. Code] or imprisoned not more than 5 years, or both.

The undersigned

(Print Name of Duly Authorized Officer)

states that he is the

(Title or Office)

of the claimant herein; that he is duly authorized to sign and file this claim on behalf of the claimant; that he has read the
foregoing statement of claimant and each statement and exhibit attached thereto and knows the contents thereof; that the same is
true to his own knowledge, except as to matters therein stated to be alleged on information and belief, and that as to those matters
he believes them to be true.

Date

Signature of Duly Authorized Officer

Date

Attorney Signature

14. RELEASE AND PENALTIES (Each claimant must sign individually. Please make additional copies of this page as necessary.)

RELEASE: The information provided in this Statement of Claim and in any attachments hereto, and any material and

information submitted before or after this Statement of Claim in regard to or in support of the claim, will be treated as public
information. The aforementioned information and materials may be made available to interested persons who make inquiries
about the claims program and individual claims filed in the program, in conformity with the Freedom of Information Act.
Any decision issued by the Commission in relation to this Statement of Claim will be made publicly available via the
Internet. By your signature on this Statement of Claim, you acknowledge that you are aware of and agree to the making of
such disclosures, and you authorize the Foreign Claims Settlement Commission and its staff to conduct any investigation
needed to decide your claim.

PENALTIES: Your attention is directed to the federal law on false statements, 18 U.S.C. section 1001, which provides:
[W]hoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United
States, knowingly and willfully–
(1) falsifies, conceals or covers up by any trick, scheme, or device a material fact;
(2) makes any false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially,
fictitious, or fraudulent statement or entry;
shall be fined under [Title 18, U.S. Code] or imprisoned not more than 5 years, or both.

I,

certify that I have read the release and agree to
(Printed Name of Claimant)

its terms. I further certify that, to the best of my knowledge and belief, the statements set forth in this Statement of Claim,
including any papers attached to, or filed with this Statement of Claim, are true and accurate, and that all material facts have
been set forth in this Statement of Claim.

Date

Claimant Signature

Date

Attorney Signature

Privacy Act Statement

The Foreign Claims Settlement Commission (the Commission) is authorized to collect the information requested on this form under 22 U.S.C. 1621 et seq.,
the Agreement Between the Government of the United States of America and the Great Socialist People's Libyan Arab Jamahiriya of August 14, 2008 and
The Libyan Claims Resolution Act of August 4, 2008, Pub. L. 110-301. The information collected on this form and submitted to the Commission will be used
to enable the Commission to carry out its statutory responsibility to determine the validity and amount of the claims against Libya. Furnishing the requested
information to the Commission is voluntary; however, failure to provide such information may result in either the delay of the adjudication or denial of the
claim. Information collected on this form may be disclosed pursuant to routine uses, published at 74 Fed. Reg. 2133 (01/14/2009). Such routine uses include:
•
To the Department of State and the Department of the Treasury in connection with the negotiation, adjudication, settlement and payment of claims;
•
To contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other
assignment for the federal government, when necessary to accomplish an agency function related to this system of records;
•
To a Member of Congress or staff acting upon the Member's behalf when the Member or staff requests the information on behalf of, and at the request of,
the individual who is the subject of the record;
•
Where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law - criminal, civil, or regulatory in
nature - the relevant records may be referred to the appropriate federal, state, local, territorial, tribal, or foreign law enforcement authority or other
appropriate entity charged with the responsibility for investigating or prosecuting such violation or charged with enforcing or implementing such law;
•
In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the Department of Justice and/or the Foreign Claims
Settlement Commission determines that the records are arguably relevant to the proceeding; or in an appropriate proceeding before an administrative or
adjudicative body when the adjudicator determines the records to be relevant to the proceeding.