International Terrorism Victim Expense Reimbursement Pro

Date App. Rec’d.__________

Date all Supporting Docu-

mentation Rec’d.__________

ITVERP Claim Number:

________________________

U. S. Department of Justice

Office of Justice Programs

Office for Victims of Crime

OMB Number 1121-0309

Expiration: 04/30/10

For Official Use Only

International Terrorism Victim Expense Reimbursement Program Application

Please type or print clearly. Attach additional paper, if necessary.

A. Application Type

Check only one. (Reminder: All applications must include an original signature and original receipts.)

_____Itemized Application

_____Interim Emergency Payment Application

_____Supplemental Application (If filling out a Supplemental Application, provide Original Claim Number: _____)

B. Victim Information

To help process your application more quickly, please read the Application Instructions for information on the required documents to be included with your application.

Please provide the following personal information on the victim:

Victim’s Full Name (First, Middle, Last):________________________________________________

Street Address: ____________________________________________________________________

City/State/Zip: _______________________________ Country: ____________________________

Telephone: ____________________ Fax: ____________________

E-mail (optional): _______________

Date of Birth: _______________

Please Complete One:

Social Security Number: _______________

Employee Identification Number: ____________

Other Identification Number (e.g., passport, driver’s license, etc.): _______________

Gender: Male ____ Female____ Place of Birth:____________ Country of Citizenship:__________

Employer (if applicable): ____________________________________________________________

Employer Street Address:____________________________________________________________

City/State/Zip: _______________________________ Country: ____________________________

Contact Person (if known): _______________ Telephone: ______________ Fax: _______________

Contact Person’s E-mail (optional): ____________________________________________________

Victim’s known children, dependents, or recipients of support (continue on Supplemental Sheet, under Section B-1):

Name: ______________________________ DOB:__________ Relationship: _______________

Do you know of anyone else who may be eligible for expense reimbursement under this program who is not listed on this application? ____ Yes ____ No

If Yes, please list all (additional information may be listed on the Supplemental Sheet in Section B-2):

Name: _________________________________ Relationship: ____________________________

Full Address: ___________________________________________________________________

Telephone: ______________ Fax: _____________ E-mail (optional): ________________________

B. Victim Information (Continued)

Check all that apply

Victim Eligibility:

____ United States Citizen/National

____ United States Government Officer

____ United States Government Employee:

____ Foreign Service National

____ Foreign Service Officer

____ Civil Servant

____ Other:_________________________

Is the Victim: Deceased ____ Minor____ Incapacitated____Incompetent____

(If the victim is deceased, a minor, incapacitated, or incompetent, please go directly to Section C. If the victim is none of these, please skip Section C and go directly to Section D.)

C. Claimant Information

Please provide the following information on the claimant.

(This section should be completed only if filing on behalf of a victim. If the victim and the claimant are the same person, the applicant may proceed directly to Section D.)

Claimant’s Full Name (First, Middle, Last):_____________________________________________

Street Address: __________________________________________________________________

City/State/Zip: _______________________________ Country: ___________________________

Telephone: ______________ Fax: ______________ E-mail (optional): _______________________

Date of Birth: ____________

Please Complete One:

Social Security Number: _______________

Employee Identification Number: ____________

Other Identification Number (e.g., passport, driver’s license, etc.): _______________

Gender: Male ____ Female____ Country of Citizenship: ________________________

Relationship to Victim: ( ) Spouse ( ) Child ( ) Parent ( ) Sibling ( ) Representative

( ) Other:________________________________________________

D. Crime Information

Please provide the following information about the act of international terrorism:

Date of crime: ________________________

Location of crime (include City and Country): ____________________________________________

Briefly describe crime (Use Supplemental Attached Form, if needed): __________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

Injuries to victim as a result of the crime: Physical____ Emotional____ Property____

Briefly describe injuries (Use Supplemental Attached Form, if needed): ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Lead investigative agency (if known): _________________________________________________

E. Expenses

To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.

Please check all applicable expenses or losses for which you are seeking reimbursement or payment from OVC. You may include related travel expenses for any of the following categories.

____ Medical Expenses (including dental and rehabilitation costs) ___________

____ Mental Health Care Services __________

____ Property Loss, Repair, and Replacement __________

____ Description of Property Loss: _______________________________________________________ ________________________________________________________________________________________________________________________________________________________________

____ Funeral and Burial Expenses __________

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

Total Amount Requested ________

Do you anticipate incurring additional cost(s) related to this act of international terrorism which may result in a claim for additional reimbursement or payment? Yes____ No____

*Please note that it is not required to convert expenses to U.S. dollars.

F. Collateral Sources (Other Sources of Financial Help)

To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.

Do you currently have, (or in the past had) any other source(s) of financial help that may cover your expenses? Yes____ No____

If “yes”, please acknowledge all of the sources of reimbursement, or payment applied for or received in relation to this crime:

____ Medical/Health Insurance ____ Disability Insurance

____ Medicare/Medicaid ____ Vocational Rehabilitation Benefits

____ Property/Auto Insurance ____ Homeowners/Renters Insurance

____ Military/Veterans’ Benefits ____ Restitution

____ Funeral/Burial Insurance ____ Emergency Assistance Programs

____ Other (please list):__________________

______________________________________

Have you previously received any funds from, or have any of your expenses been paid for the victim on this form by, the U.S. Department of Justice (or any of its bureaus or offices such as the Office for Victims of Crime or the FBI) or it’s Emergency Assistance Programs?

Yes____ No____ If “yes”, how much? $________ For what? ____________________

Please provide additional information on all of the above sources checked or received/identified (continue on Supplemental Sheet, Section F):

Source: __________________________________ Policy Number. (if applicable): _________________

Company (if applicable): ___________________________________________________________

Telephone: ______________ Fax: ______________ E-mail (optional): _______________________

Name of Individual Reimbursed: ____________________________

Please Complete One:

Social Security Number: _______________

 Employee Identification Number: ____________

Other Identification Number (e.g., passport, driver’s license, etc.): _______________

Status of Collateral Sources:

____ Claim Pending; Amount ___________

____ Claim Approved; Amount __________

F. Collateral Sources (Other Sources of Financial Help) (Continued)

Any unsatisfied judgment against a foreign government will be considered a collateral source of financial help, and your ITVERP reimbursement will be reduced accordingly, unless you agree to NOT sue the United States Government for satisfaction of that judgment by signing and dating the following:

I waive any right I may have to sue the United States Government for satisfaction and enforcement of my unsatisfied judgment against the foreign government for the act of terrorism for which I am claiming reimbursement from ITVERP.

Name Date

G. Service Provider Information

To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.

Please supply the following information on individuals or agencies that provided services to the victim related to the act of international terrorism (continue on Supplemental Sheet, Section G).

Name of Service Provider: __________________________________________________________

Street Address: __________________________________________________________________

City/State/Zip: ______________________________ Country: ____________________________

Telephone: ______________ Fax: ______________ E-mail (optional): _______________________

Type of Service Provided:___________________________________________________________

Cost of Service(s) Rendered $________ Diagnosis or Condition: ________________________

Are services ongoing? Yes____ No____

If services are ongoing, how long will they continue? ______________________________________

Were you billed for the cost of the services? Yes____ No____

Were the costs paid in full? Yes____ No____ If “yes”, full amount paid $________

Were the costs paid in part? Yes____ No____ If “yes”, partial amount paid $________

By whom were either the full or partial payments made? ___________________________________ ______________________________________________________________________________

Name/Telephone/Fax/E-mail (optional)/Claim Number (if applicable)

H. Authorization, Consents and Certifications

This release must be signed and dated before your application can be considered for expense reimbursement.

I agree to contact and repay ITVERP if I receive any payments from the persons or governments responsible for the act of international terrorism, a civil lawsuit, an insurance policy, or any other government or private agency to cover expenses for which I have already received payment from this program.

I hereby authorize any hospital, physician, funeral director, municipal authority, employer or union, insurance company, social service bureau, Social Security office, or any other person, firm, agency, or organization to furnish to the Office for Victims of Crime, ITVERP, or its representatives, any information requested, including medical records, diagnostic assessments, and mental health evaluations, needed to complete my claim for expense reimbursement. A photocopy of this authorization shall be considered as effective and valid as the original.

I hereby certify, subject to the penalty of fine or imprisonment or both, that I have provided all names and addresses of all other individuals who may be eligible to receive expense reimbursement in relation to the victim in this case, and I further certify that I have notified these individuals in writing, either by certified mail or hand delivery, that I have filed a claim for expense reimbursement in relation to the victim.

I hereby certify, subject to the penalty of fine or imprisonment or both, that I am neither directly nor indirectly responsible for the terrorist act for which I am seeking expense reimbursement.

I hereby certify, subject to the penalty of fine and imprisonment, that the information contained in the application for terrorism victim expense reimbursement is true and correct to the best of my knowledge.

_______________________________________________ ________________________________

Victim/Claimant’s Signature Date

_______________________________________________ ________________________________

Representative’s Signature (or signature of individual Date

who assisted in the preparation of this application)

Street Address: ___________________________________

City/State/Zip: ____________________________________

Telephone: _______________________________________

Email Address: ____________________________________

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