International Terrorism Victim Expense Reimbursement Program

International Terrorism Victim Expense Reimbursement Program Application

ITVERP Application Supplemental Sheets OMB 1121-0309 8.31.14

International Terrorism Victim Expense Reimbursement Program

OMB: 1121-0309

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U.S. Department of Justice OMB Number 1121-0309

Office of Justice Programs Expiration: 09/30/2014

Office for Victims of Crime



Supplemental Sheet F: MEDICAL EXPENSES

If necessary, please attach additional sheets using this format.



Medical Expense Please list each medical expense for which you are seeking reimbursement

Describe the Medical Expense



What Was the Out of Pocket Cost?


Date Medical Expense Was Incurred

Name of Service Provider



Contact Person’s Name:

E-mail

Telephone:

Provider’s Address



City

State

Zip Code

Medical Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses.

Coverage Source’s Name


Policy # - Acct # - Claim #



Contact Person’s Name:

Coverage Source’s Address



Source’s Telephone



Source’s E-mail/Fax



Medical Expense Please list each medical expense for which you are seeking reimbursement

Describe the Medical Expense



What Was the Out of Pocket Cost?


Date Medical Expense Was Incurred

Name of Service Provider



Contact Person’s Name:

E-mail

Telephone:

Provider’s Address



City

State

Zip Code

Medical Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses.

Coverage Source’s Name



Policy # - Acct # - Claim #



Contact Person’s Name:

Coverage Source’s Address



Source’s Telephone



Source’s E-mail/Fax





Please attach supporting documentation for each expense such as insurance statements,

invoices, copies of receipts, credit card statements, Explanation of Benefits, etc.





Supplemental Sheet G: MENTAL HEALTH EXPENSES

If necessary, please attach additional sheets using this format.



Mental Health Expense Please list each mental health expense for which you are seeking reimbursement

Describe the Medical Expense



What Was the Out of Pocket Cost?


Date Medical Expense Was Incurred

Name of Service Provider



Contact Person’s Name:

E-mail

Telephone:

Provider’s Address



City

State

Zip Code

Mental Health Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses.

Coverage Source’s Name


Policy # - Acct # - Claim #



Contact Person’s Name:

Coverage Source’s Address



Source’s Telephone



Source’s E-mail/Fax



Mental Health Expense Please list each mental health expense for which you are seeking reimbursement

Describe the Medical Expense



What Was the Out of Pocket Cost?


Date Medical Expense Was Incurred

Name of Service Provider



Contact Person’s Name:

E-mail

Telephone:

Provider’s Address



City

State

Zip Code

Mental Health Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses.

Coverage Source’s Name



Policy # - Acct # - Claim #



Contact Person’s Name:

Coverage Source’s Address



Source’s Telephone



Source’s E-mail/Fax





Please attach supporting documentation for each expense such as insurance statements,

invoices, copies of receipts, credit card statements, Explanation of Benefits, etc.





Supplemental Sheet H: PROPERTY LOSS EXPENSES

If necessary, please attach additional sheets using this format.



Please list in detail, your specific items below.


Item

Name


Detailed Description

Cost at time of purchase

Was the item insured?

Attached Supporting Documentation

Example:

Digital Camera



1 Canon PowerShot S95 Camera with 10 megapixels, 4x zoom, 3” LCD display and SD memory card slot.


$865.00


no


Receipt















































Please attach supporting documentation for each expense such as copies of receipts, credit card statements, pictures of the items, etc.



Supplemental Sheet I: FUNERAL & BURIAL EXPENSES

If necessary, please attach additional sheets using this format.


Please list in detail, your requested expenses below:



Type of Expense

Detailed Description

Total Cost at time of purchase

Amount covered by other sources

Purpose of Expense

Attached Supporting Documentation












































For each expense you must attach copies of supporting documentation.


Third Party Contributions: Has any other person(s) such as a family member or friend, paid for

part of the out-of-pocket funeral and/or burial expenses for which you are seeking reimbursement?

If so, complete the chart below.

Person Who Paid

Contact Information for Person(s) Who Paid

Relationship Between Claimant and Who Paid

Amount Paid


For What Expense

Name










Address, e-mail and telephone



Name

Address, e-mail and telephone




Name










Address, e-mail and telephone



Please attach supporting documentation for each expense

such as copies of receipts, credit card statements, etc.



Supplemental Sheet J: MISCELLANEOUS EXPENSES

If necessary, please attach additional sheets using this format.



Please list your specific expenses below.



Type of Expense

Detailed Description

Cost at time expense was incurred

Amount covered by other sources

Purpose of Expense

Attached Supporting Documentation

Example:


Phone bill

Phone charges from India to Knoxville, TN while in India attending to victim’s affairs – June/July 2004


$384.28USD


no


Putting victim’s affairs in order


Phone bill











































For each expense you must attach copies of supporting documentation.


Third Party Contributions: Has any other person(s) such as a family member or friend, paid for part of the out-of-pocket funeral and/or burial expenses for which you are seeking reimbursement?

If so, complete the chart below.

Person Who Paid

Contact Information for Person(s) Who Paid

Relationship Between Claimant and Who Paid

Amount Paid


For What Expense

Name


Address, e-mail and telephone



Name

Address, e-mail and telephone





For assistance call 1-800-363-0441 or e-mail [email protected]


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