International Terrorism Victim Expense Reimbursement Program

Supplemental Sheet

Section B-1: Victim Information

(All Applicants)

Known child(ren), dependent(s), or recipient(s) of victim’s support:

Name: ______________________________ DOB:__________ Relationship: ______________

Known child(ren), dependent(s), or recipient(s) of victim’s support:

Name: ______________________________ DOB:__________ Relationship: ______________

Known child(ren), dependent(s), or recipient(s) of victim’s support:

Name: ______________________________ DOB:__________ Relationship: ______________

Known child(ren), dependent(s), or recipient(s) of victim’s support:

Name: ______________________________ DOB:__________ Relationship: ______________

Known child(ren), dependent(s), or recipient(s) of victim’s support:

Name: ______________________________ DOB:__________ Relationship: ______________

Known child(ren), dependent(s), or recipient(s) of victim’s support:

Name: ______________________________ DOB:__________ Relationship: ______________

***********************************Section B-2***********************************

Do you know of anyone else who may be eligible for expense reimbursement under this program who is not party to this application? Yes____ No ____ If “yes”, please list:

Name: _________________________________ Relationship: _________________________________

Full Address: _________________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Name: _________________________________ Relationship: _________________________________

Full Address: _________________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Name: _________________________________ Relationship: _________________________________

Full Address: _________________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Name: _________________________________ Relationship: _________________________________

Full Address: _________________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Name: _________________________________ Relationship: _________________________________

Full Address: _________________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Supplemental Sheet

Section F: Collateral Sources

(All Applicants)

Please acknowledge any of the following 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 Insurance ____ Homeowners/Renters Insurance

____ Military/Veterans’ Benefits ____ Restitution

____ Payments/Compensation by Local, State, State VOCA, Federal, and/or Foreign Governments

____ Other (please list): ____________________________________________________

Have you previously received any funds from the Office for Victims of Crime or its Contractor?

Yes____ No ____ If “yes”, how much? $______ For what? ________________________

Please provide additional information on all of the above sources checked or received/identified:

Source: ____________________________________ Policy No. (if applicable): ___________________

Company (if applicable): ________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Name of Individual Reimbursed: _____________________________ SSN: ______________________

Status of Application:

____ Application Pending

____ Application Approved; Amount __________

____________________________________________________________________________________

************************************************************************************

Please acknowledge any of the following 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 Insurance ____ Homeowners/Renters Insurance

____ Military/Veterans’ Benefits ____ Restitution

____ Payments/Compensation by Local, State, State VOCA, Federal, and/or Foreign Governments

____ Other (please list): ____________________________________________________

Have you previously received any funds from the Office for Victims of Crime or its Contractor?

Yes____ No ____ If Yes, how much? $______ For what? ________________________

Please provide additional information on all of the above sources checked or received/identified:

Source: ____________________________________ Policy No. (if applicable): ___________________

Company (if applicable): ________________________________________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Name of Individual Reimbursed: _____________________________ SSN: ______________________

Status of Application:

____ Application Pending

____ Application Approved; Amount __________

____ Application Denied. If declined, please indicate reason:___________________________________ ____________________________________________________________________________________

Supplemental Sheet

Section G: Service Provider Information

(Itemized and Supplemental Applicants Only)

Please supply the following information on person(s) and/or organizations that provided services to the victim related to the act of international terrorism. Please include all documentation of services received and related costs.

Name of Service Provider: _______________________________________________________________

Street Address: ________________________________________________________________________

City/State/Zip: _______________________________ Country: ________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Type of Assistance Provided:_____________________________________________________________

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

Are services ongoing? Yes____ No ____ If Yes, how long will services 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)

******************************************************************************

Name of Service Provider: _______________________________________________________________

Street Address: ________________________________________________________________________

City/State/Zip: _______________________________ Country: ________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): ________________________

Type of Assistance Provided:_____________________________________________________________

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

Are services ongoing? Yes____ No ____ If “yes”, how long will services 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)

******************************************************************************

Name of Service Provider: _______________________________________________________________

Street Address: ________________________________________________________________________

City/State/Zip: _______________________________ Country: ________________________________

Telephone: _______________ Fax: _______________ E-mail (optional): _________________________

Type of Assistance Provided:_____________________________________________________________

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

Are services ongoing? Yes____ No ____ If Yes, how long will service 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)