Form DS-7713 Statement of Claim Related to Deportation from France Du

OMB Control No: 1405-XXXX
Expiration Date: )()(/)()(/xxxx
Estimated burden: 3 hours

U.S. Department of State

STATEMENT OF CLAIM
Related to Deportation from France During the Holocaust

,

1. Claimant
Name of Employee (Last, First, MI)

Street Address
StatelT erritory

City

Email Address

If you are filing as a representative

Country

Work Phone

Home Phone

on behalf of the estate of a deportation

(I)

Full Name of the deceased survivor or surviving spouse:

(II)

Date and place of death of survivor or surviving spouse:

(III) Official documentation

Zip/Postal Code

survivor

or the estate of a surviving

spouse,

please provide:

(mm-dd-ywy)

of the date and place of death of survivor or surviving spouse (such as a death certificate).

A copy of the court order or other official documentation
(IV) surviving spouse.

2. Legal Representative

showing that you are the authorized estate representative

of the deceased survivor or

(if any)

Note: Leave this section blank if you are submitting a claim as the representative
other legal representatives should complete this information.

of the estate of a survivor or the estate of a surviving spouse.

All

Name of Law Firm

Name of Legal Representative

Street Address
City

StatelTerritory

Email Address

Zip/Postal Code

Country

Work Phone

Home Phone

3. Nationality
BASIC CLAIM IN FORMA TION
If you are filing on your own behalf, please provide your nationality:
If you are filing as the representative of the estate of a survivor or the estate of a surviving spouse, please provide the nationality of the survivor or
surviving spouse upon that person's death:
Please provide legal documentation of your nationality or the nationality of the relevant deceased survivor or surviving spouse, such as a copy of a
passport, birth certificate, certificate of naturalization, or other appropriate documentation.
Note: Article 3 of the U.S.·France Agreement states that the Agreement shall not apply to "Holocaust
or to "Holocaust
deportation
claims of nationals of other countries who have received, or are eligible
international
agreement concluded by the Government of the French Republic addressing
Holocaust

deportation
claims of French nationals"
to receive, compensation
under an
deportation."

4. Claim Details
(a) Please indicate the category under which you are submitting this claim:

0
[1
0

0

Survivor of Deportation from France during the Second World War
Estate of Deportation

Survivor who Died between 1948 and the Present

Surviving Spouse of Individual Deported from France during the Second World War
Estate of Deported Individual's Surviving Spouse who Died between 1948 and the Ppresent

(b) Please provide all available identifying information and documentation regarding the relevant individual's deportation from France during the Second
World War, including if possible the date, convoy, and place of departure and arrival of such deportation (continue on page 2 if necessary).

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(b) Please provide all available identifying information and documentation

regarding the relevant individual's deportation from France during the Second

World War, including if possible the date, convoy, and place of departure and arrival of such deportation

(use additional sheets if necessary):

(c) If you are filing as or on behalf of the surviving spouse of the person deported as described above, please provide documentation
the deported person and indicate whether the deported person survived after the Second World War:

of the marriage to

DYes

[l

No

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5. RELEASE AND PENAL TJES (Each claimant must sign individual/y.)
By your signature on this Statement of Claim, you also acknowledge

that if you are deemed eligible and awarded compensation

application,

payment of such compensation

satisfaction

and final settlement of any claim coming within the terms of the Agreement

Government

of the United States of America on Compensation

by French Programs ("the Agreement"),

as a result of your

will be made only upon your signature of a release in which you agree to receive the payment amount in full

signed in Washington,

between the Government

for Certain Victims of Holocaust-Related

of the French Republic and the

Deportation from France Who Are not Covered

DC, on December 8,2014. Terms used in this written undertaking will have the

meaning prescribed in the Agreement.

This release form will also require that you affirm, upon receipt of the payment amount:

(1) I release and forever discharge France and any French national (including natural and juridical persons) from any liability of any kind for all claims
relating to Holocaust deportation.

(2) I forever relinquish all claims, demands, rights of action, suits, and judgments,
administrators,

that I have ever had or will have, or which my heirs, executors,

or assigns ever had or ever may have, relating to Holocaust deportation from France.

(3) I release and forever discharge the Government
agents of the Government
Holocaust deportation,

of the United States of America; its agencies or instrumentalities;

of the United States of America or the United States' agencies and instrumentalities

and officials, employees,

and

from any liability of any kind relating to

United States actions and policies affecting those claims, any associated litigation, and the United States' administration

of those

claims.

(4) I forever relinquish all claims, demands, rights of action, suits, and judgments,

that I have ever had or will have, or which my heirs, executors,

administrators,

or assigns ever had or ever may have, relating to United States actions and policies affecting claims relating to Holocaust deportation,

any associated

litigation, and the United States' administration

of those claims.

(5) I declare under penalty of perjury that I have not received, and will not at any time claim, any compensation
Holocaust deportation or under any international agreements

concluded by the Government

(6) I declare under penalty of perjury that I have not received any compensation
Holocaust deportation

or under the compensation

under French programs relating to

of the French Republic relating to Holocaust deportation.

under any other State's compensation

program relating specifically to

programs of any foreign institution relating specifically to Holocaust deportation."

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 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 (mm-dd-wyy)

Signature of Claimant

Date (mm-dd-wyy)

Signature of Legal Representative

PRIVACY ACT STATEMENT
tUTHORITIES: The information is sought pursuant to the State Department Basic Authorities Act, 22 U.S.C. §§ 2651a, 2656 and 2668a, and the Agreement Between The
b~vernments of the United States of America and the French Republic on Compensation for Certain Victims of HOlocaust-RelatedDeportation from France Who Are not
~overed by French Programs.
PURPOSE: The information solicited in this form will be used to evaluate the claims submitted by individuals who survived deportation from France during the Second Worle
f,var as part of the persecution carried out by the German Occupation authorities or the Vichy Government; their surviving spouses; or their assigns.
~OUTINE USES: The information on this form may be shared with federal, state, and local government agencies: and members of Congress and the Governmen
f,ccountabilily Office; French government officials; U.S. federal and state courts; and foreign courts. The information may also be made available to Officialsof other foreign
~overnments. More information on the Routine Uses for the system can be found in the System of Records Notice STATE-54, Records of the Office of the Assistant legal
!6.dviserfor International Claims and Investment Disputes.
PISClOSURE: Providing this information is voluntary. Failure to provide the information requested in this form may result in denial of your claim.
Paoerwork Reduction Act
he Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that this information is being collected to ensure that your claim contains all thE
nformation required to process it fully. The Office of the legal Adviser, International Claims and Investment Disputes will use this information to process your claim.
Response is voluntary. The information you provide on this form will only be shared with persons who have an official need to know and will be protected from public
~iscJosure pursuant to the provisions of the Privacy Act, 5 U.S.C. §552a(b). The estimated time to complete this form is 3 hours. You may send comments regarding the
jaccuracy of this estimate and any suggestions for reducing the time for completion of the form to U.S Department of State, Office of the legal Adviser, Room 4325, 2201 C
Istreet NW, Washington DC 20520. ATTN: Deportation Claims Form. An agency may not conduct or sponsor, nor is a person required to respond to, a collection 0
nformation unless it displays a current valid OMB Control Number.

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