FCSC Form 1-12 Statement of Claim

OMB Approval Number: xxxx-xxxx
Expiration Date: XX/XX/20XX

U.S. DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION

(FOR FCSC USE ONLY)
CLAIM NO. IRQ- I -

STATEMENT OF CLAIM
FOR FILING OF CLAIMS IN THE IRAQ CLAIMS PROGRAM, PURSUANT TO THE CLAIMS
SETTLEMENT AGREEMENT BETWEEN THE GOVERNMENT OF THE UNITED STATES OF
AMERICA AND THE GOVERNMENT OF THE REPUBLIC OF IRAQ DATED SEPTEMBER 2, 2010,
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 NOVEMBER 14, 2012.
NOTE: Please read the instructions carefully before completing this form. Additional pages may be appended to
this form as necessary.

CONTACT INFORMATION

1. CLAIMANT
Name of Claimant
(Last)

(Middle)

(First)

(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 (if any)
Name of Legal Representative
(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. The estimated burden
associated with this collection of information is 2.0 hours per respondent or recordkeeper.

FORM FCSC 1-12
December 2012

3. U.S. NATIONALITY

BASIC CLAIM INFORMATION

Please state how and when you acquired U.S. nationality 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.)

4. CLAIMS FOR ADDITIONAL COMPENSATION BY PERSONS WHO HAVE RECEIVED COMPENSATION UNDER THE
CLAIMS SETTLEMENT AGREEMENT FROM THE DEPARTMENT OF STATE
4.1

The Letter of Referral from the Department of State states that the category of referred special circumstance claims consists of
claims for compensation: (i) which are in addition to amounts already received from the Department of State under the Claims
Settlement Agreement, (ii) where such compensation did not include economic loss based on a judgment against Iraq.

4.1.1

Did the claimant receive compensation from the Department of State pursuant to the Claims Settlement
Agreement?

4.1.2

Did such compensation include compensation for economic loss based on a judgment against Iraq?

4.1.3

Please attach evidence substantiating the answers to the aforementioned questions.

4.2

Please describe on an attached submission the special circumstances of the serious personal injury on which the claim is based
(including serious physical, mental, or emotional injury arising from sexual assault, coercive interrogation, mock execution, or
aggravated physical assault).

4.3

Please describe on an attached submission: (i) the nature and extent of the injury; (ii) the impact that the injury has had on
the claimant's ability to perform major life activities, both on a temporary and permanent basis; and (iii) the degree to which
the injury has resulted in disfigurement to the claimant, if applicable. Please also provide all evidence substantiating the
injury described.

4.4

Please indicate whether medical treatment was received for the injuries described above?
4.4.1 If the answer to the aforementioned question is yes, please submit all evidence substantiating the medical treatment.

4.5

Please attach any other evidence which you believe substantiates the injury described.

5. 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, 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, 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, including 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 that 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
(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

Legal Representative Signature

6. FEES LIMITATION (Must be signed by claimant's Legal Representative (if any).)
LEGAL FEES: Your attention is directed to 22 U.S.C. § 1623(f), which states: "No remuneration on account of services rendered on behalf
of any claimant in connection with any claim filed with the Commission under this title shall exceed 10 per centum of the total amount paid
pursuant to any award certified under the provisions of this title, on account of such claim. Any agreement to the contrary shall be unlawful
and void."

I,

certify that I have read 22 U.S.C.§ 1623(f), and that I agree to, and I am bound by, its terms.
(Name of Legal Representative)

Date

Legal Representative Signature

Privacy Act Statement
The Foreign Claims Settlement Commission (the Commission) is authorized to collect the information requested on this form (or requested at any other time
regarding this claim) under 22 U.S.C. 1621 et seq., and the Agreement Between the Government of the United States of America and the Government of the
Republic of Iraq dated September 2, 2010. The information collected will be used to enable the Commission to carry out its statutory responsibility to
determine the validity and amount of the claims against Iraq submitted to it. 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 may be disclosed pursuant to
routine uses, published at ____ Fed. Reg. _____ (xx/xx/xxxx). 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 the Commission, or 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.