Personal Representative’s Authorization for Communication and Correspondence

U.S. Victims of State Sponsored Terrorism Fund
Personal Representative’s Authorization For
Communication and Correspondence
OMB No. 1123-0013
Expires XX/XX/XXXX

If a Personal Representative (or authorized representative of the Personal Representative) wants to authorize the
U.S. Victims of State Sponsored Terrorism Fund (the “Fund”) to communicate with an individual regarding the
claim, please provide the individual’s name and contact information, and sign and date the following
authorization.1
Last Name

First Name

Middle Name

Law Firm Name (if applicable)
Mailing Address
City
Email Address

State

Zip/Postal Code
Telephone

Country (if not in U.S.)
Facsimile

I authorize the Special Master, the Special Master’s designees, the U.S. Department of Justice, and agency
contractors assisting in the administration of the Fund to contact the attorney or other person identified above
regarding my claim.

______________________________________________________

_______________________________

Signature of Personal Representative

Date of Signature
(mm/dd/yyyy)

______________________________________________________

Print Name

1

Applicants should not submit this form for attorneys or authorized representatives who were previously identified in the Application
Form.