United States Victims of State Sponsored Terrorism Fund

United States Victims of State Sponsored Terrorism Fund

Notice of Filing Claim

Instructions to Decedent’s Personal Representative:

You are required to notify all living relatives and potentially interested parties, as listed below, that you are filing a claim on behalf of the decedent. Follow the instructions below:

1. Complete Part V of the Application Form by following the instructions for that Part. You are required to list in Part V of the Application Form and deliver a copy of this Notice to the following people:

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

• The Executor or Administrator and beneficiaries of the Decedent’s will and 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.

2. Fill out a separate copy of this page for each person to whom you are required to provide a Notice of Filing as listed in Part V of the Application Form. Fill out the name and address of the person to whom you are providing the Notice and insert the name of the Decedent in the spaces provided below as indicated. You must provide this Notice to all living relatives and potentially interested parties, regardless of whether or not they are or will be included in the distribution plan.

3. Deliver each Notice personally or by certified mail, return receipt requested. Make a copy of the Notice for your records prior to delivery.

4. Complete the date and method of delivery in the appropriate fields in Part V of the Application Form for each individual.

________________________________________________________________________

* The Personal Representative must notify everyone specified in Part VII.2 of the Notice published in the Federal Register. Use of this particular Notice of Filing Claim form is not required; however, any other notification must meet all of the requirements in Part VII.2.

United States Victims of State Sponsored Terrorism Fund

Notice of Filing Claim

To:

Name:
Address:

You are receiving this Notice to inform you that a claim on behalf of ________________________ (insert name of Decedent) is being filed with the U.S. Victims of State Sponsored Terrorism Fund (“the Fund”). The claim is being filed by ____________________________________ (insert name of Personal Representative).

The rules that govern the Fund state that only one claim may be filed in connection with the death of a Decedent and that the claim must be filed by the Decedent’s Personal Representative. The rules also state that any payment from the Fund shall be paid to the Personal Representative and that the Personal Representative is required to distribute the award among the Decedent’s beneficiaries in accordance with the laws of the Decedent’s domicile.

The Personal Representative is informing you that a claim is being filed on behalf of _______________________ (insert name of Decedent) because the Personal Representative is required to give notice of claim filing to the Decedent’s immediate family; to the Executor, Administrator, and beneficiaries of the Decedent’s will and life insurance policies; and to other people who might reasonably have an interest in any payment that may be made from the Fund.

You are not required to take any action in response to this Notice. However, any objection to the filing of the claim must be made within 30 days after the claim has been filed, which could be as soon as 30 days from the date this Notice was mailed or otherwise provided to you.

If you want to learn more about the Fund, please visit the Fund’s website at www.usvsst.com, or call 1-855-720-6966; outside the U.S. please call 1-614-553-1013.

Dated: __/__/____

From:

Name:
Address:
Telephone: