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: ____________________________________