Draft USVSST Fund Application Form

U .S. Victims of State Application Form Last 4 of Victim’s SSN or National ID No.

Sponsored Terrorism Fund OMB No. [XXX-XXXX]

Instructions:

Please complete the questions included in this Application (the “Application Form”) as your submission for compensation from the United States Victims of State Sponsored Terrorism Fund (the “Fund”). If you wish to submit a claim to the Fund, you must either complete this Application Form or submit an application electronically by visiting www.usvsst.com. Only one application may be submitted for each claim.

When completing this Application Form, you must:

• Print your answers using black or blue ink.

• Submit your answers in English.

• Submit the signed Signature Page with your completed Application Form.

• Submit required documentation with your completed Application Form.

Filing Deadline:

Applications must be submitted by [DATE 90 DAYS from Fed. Register publication of notice], unless your claim is based on a final judgement obtained on or after [FR Publication Date], in which case it must be submitted no later than 90 days after the date of obtaining the final judgment.

Required Documentation Checklist:

A document checklist is provided with this form (see Part [VI] of the Application Form) to assist you in gathering and submitting the documents needed to process your claim.

Submitting Your Application Form:

Your completed Application Form may be mailed to the Claims Administrator via first-class or overnight mail, postage prepaid, addressed as follows:

By regular mail: By overnight mail:

U.S. Victims of State Sponsored Terrorism Fund U.S. Victims of State Sponsored Terrorism Fund

c/o GCG c/o GCG

PO Box 10299 5151 Blazer Parkway

Dublin, OH 43017-5899 Dublin, OH 43017

An Application Form may also be submitted as an email attachment to [email protected] or faxed toll free to (855) 409-7130. If you are outside the United States, the toll fax number is (614) 553-1426.

The Fund keeps all documents you submit with your application. Please make copies for your records of any documents you submit, including a copy of your completed Application Form.

It is very important that you keep the Fund informed of any changes in your mailing address, telephone number, or email address because this is the information that the Fund will use to contact you about your application.

If you need assistance completing this Application Form, or have any questions, please call our toll-free helpline at (855) 720-6966. If you are calling from outside the United States, please call collect at (614) 553-1013.

The information collected in this application is for the purpose of assessing the eligibility of your claim for compensation from the Fund, and for the purpose of determining the appropriate amount of compensation. Completion of this Application Form is estimated to take 3 hours.

The Fund will protect the confidentiality of information provided in this application and will not publish the names or personally identifiable information (PII) of Victims or applicants.

PART I – VICTIM AND APPLICANT INFORMATION

The term “Victim” refers to a U.S. person who (1) has secured a final judgment in a United States district court under state or federal law against a state sponsor of terrorism and arising from an act of international terrorism, for which the foreign state was found not immune under section 1605A, or section 1605(a)(7), of title 28, United States Code (FSIA), or (2) was held hostage at the United States Embassy in Tehran, Iran during the period beginning November 4, 1979, and ending January 20, 1981, or the spouse or child of a former hostage as described in this paragraph, if such person is identified as a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court for the District of Columbia. The term “Applicant” refers to the individual who is filing the claim to seek compensation for the Victim. Individuals who are filing a claim on their own behalf are both the Applicant and the Victim.

INFORMATION ABOUT THE VICTIM

1. Complete the information below.

Last Name

First Name

Middle Name

Mailing Address

City

State

Zip/Postal Code

Country (if not in U.S.)

Home Phone

Cell Phone

Facsimile

Email Address

Date of Birth

Is the VICTIM a U.S. citizen? Yes No Provide the VICTIM’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any:________________ If the Victim does not have a SSN or TIN, or is not a U.S. citizen, provide the following:

National Identification Number

Country of Citizenship

Passport Number

Passport Country

Has the Victim ever gone by any other names (e.g., maiden name)? If Yes, provide the following:

Last Name

First Name

Middle Name

INFORMATION ABOUT THE APPLICANT

2. In what capacity are you filing the claim? Select one from the list below:

   • Self – I am the Victim. You do not need to complete the remaining information in this section – skip to Question 3.

   • Personal Representative of a deceased individual. In addition to completing the applicable sections below, you must complete Part [V] of the Application Form.

   • Parent or guardian of a Victim who is a minor. Please provide additional information below:

     • I have sole legal custody of the minor.

     • I share or have joint legal custody of the minor.

   • Guardian of a non-minor.

If there is a co-Personal Representative or if you share joint custody of a minor, you also must provide that individual’s information below.

If you are an attorney who is completing this form on your client’s behalf, complete the information below about the Applicant and then provide your information in Question 3.

If you are the Applicant and there is someone whom you would like to be able to speak on your behalf or find out information about the claim (e.g., a spouse or child), provide their contact information below (other than an attorney who should fill out Question 3).

Complete the following information for the Applicant:

Last Name

First Name

Middle Name

Mailing Address

City

State

Zip/Postal Code

Country (if not in U.S.)

Home Phone

Cell Phone

Facsimile

Email Address

Is the Applicant a U.S. citizen? Yes No Provide the Applicant’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any: ________________ If the Applicant does not have an SSN or TIN or is not a U.S. citizen, provide the following:

National Identification Number

Country of Citizenship

Passport Number

Passport Country

Alternative Contact: If there is someone whom you would like to be able to speak on your behalf or find out information about the claim (e.g., a spouse or child), provide their contact information.

Last Name

First Name

Middle Name

Mailing Address

City

State

Zip

Country (if not in U.S.)

Telephone

Email Address

If applicable, complete the following information about the person with whom you share joint representation or custody of the Victim. Note: Both signatures are required wherever the Fund asks for a signature.

Last Name

First Name

Middle Name

Mailing Address

City

State

Zip/Postal Code

Country (if not in U.S.)

Home Phone

Cell Phone

Facsimile

Email Address

Is the person a U.S. citizen? Yes No Provide the person’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any: ________________ If the person does not have an SSN or TIN or is not a U.S. citizen, provide the following:

National Identification Number

Country of Citizenship

Passport Number

Passport Country

INFORMATION ABOUT THE APPLICANT’S ATTORNEY (IF APPLICABLE)

3. If an attorney is representing you with this claim, fill out the information below: Note: All communications from the Fund will be with the attorney you identified unless your attorney instructs us otherwise in writing. In addition, you must provide documentation (signed by you and your attorney) of your counsel’s authority to represent you and you and your attorney must complete the certification in Part [IV] acknowledging that attorneys may not charge, receive, or collect any payment of fees and costs that in the aggregate exceed 25% of any payments. Counsel must submit a separate Application Form on behalf of each represented individual.

Last Name		First Name		Middle Name
Law Firm Name
Mailing Address
City	State		Zip/Postal Code		Country (if not in U.S.)
Email Address		Telephone		Facsimile

PART II – ELIGIBILITY FOR COMPENSATION

In order for the Victim to receive compensation from the Fund, the Applicant must complete either Part [II.A] or [II.B] below and provide the appropriate supporting documents, as applicable. See Part [VI] below, which lists the required supporting documents you must submit to support each claim type.

A. VICTIM WHO IS A HOLDER OF A FINAL JUDGMENT

Check the box below and answer each question if the Victim is the holder of a final judgment issued by a United States District Court under state or federal law, awarding the Victim compensatory damages on a claim or claims brought by the Victim arising from acts of international terrorism for which the foreign state was found to not be immune from the jurisdiction of the courts of the United States under section 1605A or section 1605(a)(7) (as such section was in effect on January 27, 2008) of title 28, United States Code (FSIA).

Please Note: Judgment creditors in Peterson v. Islamic Republic of Iran, No. 10 Civ. 4518 (S.D.N.Y.) and settling judgment creditors in In re 650 Fifth Avenue & Related Properties, No. 08 Civ. 10934 (S.D.N.Y., filed Dec. 17, 2008) must read the Part [VI.] of the Notice. In addition, a Victim seeking a conditional payment must sign the certification in Part [IV].

HOLDER OF A FINAL JUDGMENT

4. Were any immediate family member(s) of the Victim identified in the final judgment?

Yes No

5. List any immediate family member(s) that were identified. Immediate family members include, but are not limited to, the spouse, former spouse(s), children, other dependents, siblings, and parents of the Victim. If more than two family members were identified in the final judgment, identify each family member by copying this page, completing this section for each one, and including the additional page(s) with the Application Form submittal:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Telephone			Relationship to the Victim

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Telephone			Relationship to the Victim

6. Is the Victim a judgment creditor in Peterson v. Islamic Republic of Iran or settling judgment creditor In re 650 Fifth Avenue & Related Properties? Yes No

[Answer the questions below only if you answered yes to question 6.]

1. Is the Victim electing to participate in the Fund? Yes No

2. If yes, did the Victim separately notify the Special Master in writing? Yes No

Date the Special Master was notified: ___________________

3. If no, is the Victim seeking a Conditional Payment? Yes No

7. Did the Victim or the Victim’s representative file a claim with the September 11^th Victim Compensation Fund of 2001?

Yes No

[Answer the questions below if you answered yes to question 7.]

1. Did the Victim receive an award or an award determination (including a determination that denied an award)? Yes No

2. Did you and the Victim’s heirs and beneficiaries receive compensation? Yes No

Please identify the family members who received an award from the September 11^th Victim Compensation Fund of 2001. If more than two family members received an award, identify each family member by copying this page, completing this section for each one, and including the additional page(s) with the Application Form submittal:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Telephone			Relationship to the Victim

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Telephone			Relationship to the Victim

8. Are you the family member of a victim of the September 11^th terrorist attacks? Yes No

1. If so, did you receive an award or award determination from the September 11^th Victim Compensation Fund of 2001? Yes No

B. VICTIM WHO WAS HELD HOSTAGE OR SPOUSE OR CHILD OF PERSON HELD HOSTAGE

Check one of the boxes below and answer each question if you are, or are seeking compensation for, a Victim who was taken and held hostage from the U.S. Embassy in Tehran, Iran, during the period beginning November 4, 1979, and ending January 20, 1981, or the spouse or child of a former hostage as described in this paragraph, if such person is also identified as a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court for the District of Columbia.

HELD HOSTAGE

9. Date the Victim was taken hostage: ___________________

10. Date the Victim was released: ___________________

11. Is the Victim a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court for the District of Columbia? Yes No

SPOUSE OF PERSON HELD HOSTAGE

12. Name of hostage: ___________________

13. Date the spouse was married to the former hostage: ___________________

14. Did the marriage continue through January 20, 1981? Yes No

15. Is the spouse a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court for the District of Columbia? Yes No

CHILD OF PERSON HELD HOSTAGE

16. Name of hostage: ___________________

17. Date of birth: ___________________

18. Was the child adopted by the former hostage? Yes No

19. Date of adoption: ___________________

20. Is the child a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court for the District of Columbia? Yes No

PART III – OTHER INFORMATION IN SUPPORT OF APPLICATION

INFORMER INFORMATION (IF APPLICABLE)

Complete this section only if you are seeking additional compensation as an informer. A Victim who meets the eligibility requirements of Part [II] above and identifies and notifies the Attorney General in writing of funds or property of a state sponsor of terrorism, or held by a third party on behalf of or subject to the control of that state sponsor of terrorism, may be eligible to receive an award of 10% of the funds deposited in the Fund if the other conditions in 42 U.S.C. § 10609(g) are met.

21. Has the Victim or Applicant contacted the Attorney General? Yes No

1. If Yes, please provide the date of the communication and identify the person notified:

___________________________________________________________________________

___________________________________________________________________________

COMPENSATION SOURCES OTHER THAN THIS FUND

All Applicants must complete this section. Please identify compensation from any source other than this Fund that the Victim, or the Victim’s beneficiaries, received or is entitled to receive as a result of the act of international terrorism that gave rise to his or her final judgment. Sources other than this Fund include, but are not limited to, life insurance; pension funds; death benefit programs; payments by federal, state, or local governments (including payment from the September 11^th Victim Compensation Fund of 2001); and court awarded compensation related to the act that gave rise to the judgment.

22. Has the Victim, or the Victim’s beneficiaries received, or is entitled to receive any of the following:

Program/Benefits	Y/N	Amount	Source(s)
Life insurance	Yes No
Pension funds	Yes No
Death benefit programs	Yes No
Payments by federal, state, or local governments (including payment from September 11th Victim Compensation Fund of 2001)	Yes No
Court awarded compensation related to the act which gave rise to the judgment	Yes No

23. Please identify any other sources of compensation not listed above:

Type

Amount

Source

Please note that it’s the Applicant’s obligation to keep the Fund apprised of any compensation that the Victim, or the Victim’s beneficiaries, received or is entitled to receive from sources other than this Fund throughout the life of the Fund.

ADDITIONAL INFORMATION (Optional)

Use the area below (and any additional pages) to provide any other information that may be relevant to the individual circumstances of this claim. Please also identify and submit any additional documents not already requested that might be relevant.

PART IV – SIGNATURES AND CERTIFICATIONS

By submitting this form, you are agreeing that you understand the notices below (continued on the following page) regarding your waiver of rights, the Privacy Act, authorization to communicate with your attorney or other representative, and the limitation on attorney fees.

Privacy Act Notice:

By submitting this form, you are authorizing the U.S. Department of Justice to collect this information as allowed by the Justice for United States Victims of State Sponsored Terrorism Act, 42 U.S.C. § 10609. The information you submit in your claim is for official use by the U.S. Department of Justice for the purposes of determining your eligibility for, and the amount of, compensation you may receive under your claim to the U.S Victims of State Sponsored Terrorism Fund (“the Fund”). Provision of this information is voluntary; however, failure to provide complete information may result in a delay in processing or a denial of your claim. Information you submit regarding your claim may be disclosed by the Department of Justice only in accordance with the provisions of the Privacy Act, and for the routine uses indicated below:

1. 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 – 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.

2. To any person or entity that the Special Master or the Special Master’s designee has reason to believe possesses information regarding a matter relating to the Fund or the administration thereof, to the extent deemed to be necessary by the Special Master or her designee in order to elicit such information or cooperation from the recipient for use in the performance of an authorized activity of the Fund.

3. In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the Department of Justice 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.

4. To an actual or potential party to litigation or the party’s authorized representative for the purpose of negotiation or discussion of such matters as settlement, plea bargaining, or in informal discovery proceedings.

5. To the news media and the public, when information related to a claim is at issue in another civil or criminal proceeding, unless it is determined that release of the specific information in the context of a particular case could constitute an unwarranted invasion of personal privacy.

6. 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 the administration of the Fund.

7. To a former employee of the Department for purposes of: responding to an official inquiry by a federal, state, or local government entity or professional licensing authority, in accordance with applicable Department regulations; or facilitating communications with a former employee that may be necessary for personnel-related or other official purposes where the Department requires information and/or consultation assistance from the former employee regarding a matter within that person’s former area of responsibility.

8. 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.

9. To the National Archives and Records Administration for purposes of records management inspections conducted under the authority of 44 U.S.C. §§ 2904 and 2906.

10. To such recipients and under such circumstances and procedures as are mandated by federal statute or treaty.

11. Records relating to an individual who was notified that an award was subject to rescission or recoupment, and that the paid award amount was to be returned to the United States, where the individual has not complied, may be referred to the U.S. Department of the Treasury for collection under the Treasury Offset Program, as authorized by 31 U.S.C. 3716 and other applicable law.

By this submission, you authorize the U.S. Department of Justice to disclose any records or information relating to your claim for the routine uses identified above and for the purpose of determining qualification and/or compensation of your claim specifically to: agency contractors assisting in the administration of the Fund; other federal, state, or local agencies, including the U.S. Department of Treasury; and other individuals or entities having information related to the claim, such as insurers and employers.

Paperwork Reduction Act Notice:

This request is in accordance with the Paperwork Reduction Act of 1995. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it contains a currently valid OMB approval number. We try to create forms and instructions that are accurate, can be easily understood, and that impose the least possible burden on you. It is estimated that respondents will complete the form in an average of 3 hours.

Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of the Special Master, U.S. Department of Justice, 950 Pennsylvania Ave, NW, Washington, DC 20530; OMB control number [XXXX-XXXX].

Instructions: Please review the following statements and initial where indicated. Sign and date the form, and print your name at the end of the form.

For all Applicants, please initial in acknowledgement of the following:

_______ Initials

I certify, under oath, subject to penalty of perjury or in a manner that meets the requirements of title 28 U.S.C. § 1746, that the information provided in the Application and any documents submitted in support of the claim are true and accurate to the best of my knowledge, and I agree that any payment made by the Fund is expressly conditioned upon the truthfulness and accuracy of the information and documentation submitted in support of the claim. Where a Victim is represented by a third party, such as a Victim’s legal guardian, the Personal Representative of the decedent Applicant’s estate, or other person legally authorized to act for the Victim, these persons must have authority to certify on behalf of the Victim.

Continued on the next page

_________ Initials

I understand that false statements or claims made in connection with the claim may result in fines, imprisonment and/or any other remedy available by law to the federal government, including as provided in 18 U.S.C. § 1001, and that claims that appear to be potentially fraudulent or to contain false information will be forwarded to federal, state, and local law enforcement authorities for possible investigation and prosecution.

_________ Initials

If I receive payment under the Act, I agree and accept that the United States shall be subrogated to the rights of the Victim (and any of his or her heirs, successors, or assigns) to the extent and in the amount of such payment, but that, to the extent amounts of damages remain unpaid and outstanding to the Victim following any payments made under this Act, each Victim shall retain creditor rights in any unpaid or outstanding amounts of the judgment, including any prejudgment or post-judgment interest, or punitive damages, awarded by a United States district court pursuant to a judgment.

For Applicants who are represented by an attorney, you and your attorney must initial the following:

_________ Initials

Notwithstanding any contract, an attorney representing a Victim may not charge, receive, or collect, and the Special Master will not approve, any payment of fees and costs that in the aggregate exceeds 25 percent of any payment made under this title on such claim. The attorney shall certify his or her compliance with this section and shall provide such information as the Special Master requires ensuring such compliance. An attorney who violates this limitation on fees shall be fined under Title 18, United States Code, imprisoned for not more than 1 year, or both.

For Applicants, if the Victim is a judgment creditor in Peterson v. Islamic Republic of Iran or settling judgment creditor in In re 650 Fifth Avenue & Related Properties seeking conditional payment, please initial the following:

_________ Initials

I understand that, notwithstanding my eligibility for payment and the deadline for initial payments set forth in the Act, the Special Master shall allocate but withhold payment until such time as an adverse final judgment is entered in Peterson v. Islamic Republic of Iran, No, 10 Civ. 4518 (S.D.N.Y.) and in In re 650 Fifth Avenue & Related Properties, No. 08 Civ. 10934 (S.D.N.Y., filed Dec. 17, 2008).

For Applicants with an attorney or other authorized representative or alternative contact, please initial in acknowledgment of the following:

_________ Initials

I authorize the Special Master, the Special Master’s designees, the United States Department of Justice, or agency contractors assisting in the administration of the Victims of State Sponsored Terrorism Fund to contact my attorney or other persons authorized to act on my behalf.

For Applicants filing on behalf of a deceased individual, please initial in acknowledgment of the following:

_________ Initials

I certify that I have provided the required Notice of Filing of claim to all of the decedent’s living relatives and potentially interested parties by either personal delivery or certified mail, return receipt requested, and that I am not aware of anyone else to whom such notice should be provided.

___________________________________________ _______________________________

Signature of Applicant or Authorized Representative Date of Signature (mm/dd/yyyy)

___________________________________________

Print Name

PART V - ADDITIONAL INFORMATION FOR CLAIM FILED FOR DECEASED INDIVIDUALS

This part is for Applicants who are filing a claim on behalf of a deceased individual.

1. Have you been appointed by a court as the Personal Representative for the deceased individual?

Yes No

If No, have you attempted to be appointed the Personal Representative by a court?

Yes No

If yes, explain why you were not appointed as the Personal Representative by a court or attach a statement to your Application Form with the explanation.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. Did the decedent leave a will?

Yes No Do Not Know

NOTICE TO INDIVIDUALS OF FILING OF CLAIM

You are required to notify the following people that you are filing a claim on behalf of the decedent:

• The immediate family of the decedent (including, but not limited to, the spouse, former spouse(s), children, other dependents, siblings, and parents);

• The executor/administrator and beneficiaries of the decedent’s will;

• The beneficiaries of the decedent’s life insurance policies; and,

• Any other person who may reasonably be expected to assert an interest in an award or to have a cause of action to recover damages relating to the wrongful death of the decedent.

The “Notices & Updates” page of the Fund website contains the notice you must provide to the required individuals. You are required to provide this notice to everyone in the four categories above, even if they are not included in the decedent’s will.

Please complete the information in the following sections:

1. Decedent’s mother – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

2. Decedent’s father – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

3. Did decedent have a spouse or partner?

Yes - spouse Yes – partner No

If Yes – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

4. Did decedent have a former spouse or partner?

Yes – former spouse Yes – former partner No

If Yes – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

5. Did decedent have siblings?

Yes No

If Yes, indicate how many siblings the decedent had, including siblings who are deceased: ________

Complete the information below for each sibling. If the decedent had more than two siblings, identify each sibling by copying this page, completing a section for each sibling, and including the additional page(s) with the Application Form submittal:

Sibling 1 – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

Sibling 2 – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

6. Did decedent have dependents (including biological or adopted children)?

Yes No

If Yes, indicate how many dependents the decedent had, including dependents who are deceased:___

Complete the information below for each dependent. If the decedent had more than two dependents, identify each dependent by copying this page, completing a section for each dependent, and including the additional page(s) with the Application Form submittal:

Dependent 1 – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

Dependent 2 – this individual is:

Deceased (only name required) Living but address unknown Living and information below:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone

7. Are there any other potential beneficiaries or persons who may have an interest in the claim?

Yes No

If Yes – complete the information below:

Last Name		First Name			Middle Name
Relationship to Victim
Mailing Address
City	State			Zip/Postal Code		Country (if not in U.S.)
Email Address			Telephone
Describe interest in claim

PART VI – DOCUMENT CHECKLIST

You must provide the documentation described below to establish eligibility for payment under the Act. In certain cases, the Special Master may request additional documentation. Providing thorough documentation is the best way to ensure your application is processed quickly. All documents you submit to establish eligibility will be reviewed and considered by the Special Master.

Any requests for waiver of a documentation requirement or an extension of time in which to submit a particular document must be submitted to the Special Master in writing at least 20 business days prior to the application deadline. Decisions to waive a documentation requirement or to extend the time to submit a particular document are wholly within the discretion of the Special Master.

You must submit all supporting documentation with your application.

DOCUMENT REQUIREMENTS TO ESTABLISH ELIGIBILITY

An Applicant who seeks to establish eligibility for payment on the basis of a final judgment, as described in Part [II.A] above must submit:

	Attached?
A copy of the final judgment.

An Applicant who seeks to establish eligibility for payment for a person who was held hostage in Tehran, Iran, during the period beginning November 4, 1979, and ending January 20, 1981, as described in Part [II.B] above must submit:

	Attached?
Verification of the date on which the Victim was taken hostage from the United States Embassy in Tehran, Iran.
A Verification of the date on which the Victim was released from the United States Embassy in Tehran, Iran.
Verification that the Victim is a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court of Columbia.

An Applicant who seeks to establish eligibility for payment for the spouse of a person who was held hostage in Tehran, Iran, during the period beginning November 4, 1979, and ending January 20, 1981, as described in Part [II.B] above must submit:

	Attached?
A copy of a marriage certificate showing the date of marriage.
An affirmation that the marriage continued through January 20, 1981.
A copy of the divorce, if the Applicant is no longer married to the Victim.
Verification that the spouse is a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court of Columbia.

An Applicant who seeks to establish eligibility for payment for the child of a person who was held hostage in Tehran, Iran, during the period beginning November 4, 1979, and ending January 20, 1981, as described in Part [II.B] above must submit:

	Attached?
A copy of a birth certificate or adoption decree showing a date of birth or adoption prior to January 20, 1981.
Verification that the child is a member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court of Columbia.

DOCUMENT REQUIREMENTS FOR REPRESENTATIVES

Please note: In the case of claims brought by a foreign citizen on behalf of a decedent Victim, the Special Master may alter the document requirements.

	Attached?
Personal Representative of deceased Victim: Must show sufficient evidence of authority to represent the estate of a decedent by submitting copies of relevant legal documentation, such as court orders; letters testamentary or similar documentation; proof of the purported Personal Representative’s relationship to the decedent; and copies of wills, trusts, or other testamentary documents.
Representative of minor Victim: A copy of a court order or other document issued by an official showing appointment as the guardian or other authorized representative of the minor Victim.
Representative of non-minor Victim: A copy of a court order or other document issued by an official showing appointment as the guardian or other authorized representative of the incompetent Victim.

DOCUMENT REQUIREMENTS FOR APPLICANTS AND VICTIMS REPRESENTED BY AN ATTORNEY

	Attached?
Documentation of counsel’s authority to represent the applicant, such as a copy of the retainer agreement or contract for legal services signed by both the applicant and the attorney.

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