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pdfU.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
Instructions:
Please complete the questions included in this Application Form (the “Application Form”) as your submission for
compensation from the U.S. 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 Form electronically by visiting
www.usvsst.com. Only one application may be submitted for each claim and only the Personal Representative may
submit a claim for a deceased Victim.
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.
The Fund keeps all documents you submit with your Application Form. Please make copies for your records of any
documents you submit, including a copy of your completed Application Form.
Filing Deadline:
A claim based on a final judgment obtained on or after July 14, 2016 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 (Part VI of the Application Form) to assist you in gathering and
submitting the document(s) 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:
U.S. Victims of State Sponsored Terrorism Fund
c/o GCG
PO Box 10299
Dublin, OH 43017-5899
By overnight mail:
U.S. Victims of State Sponsored Terrorism Fund
c/o GCG
5151 Blazer Parkway, Ste A
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.
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 claim.
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.
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October 2016 Version 2.0
U.S. Victims of State Sponsored Terrorism Fund
Application Form
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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 (the “Act”), codified at 42 U.S.C. § 10609 (2015). The
information you submit in your claim, including but not limited to your Social Security Number, 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 Fund. In addition, Executive Order 9397 (November 22, 1943) authorizes federal
agencies to use Social Security numbers as individual identifiers to distinguish between people with the same or similar
names, and 5 U.S.C. § 5514, 26 U.S.C. §§ 6402, 6331, 31 U.S.C. §§ 3711–20E, 42 U.S.C. § 664, and other applicable legal
authorities, authorize the Department of the Treasury and other officials disbursing federal payments to use individual
Social Security numbers to identify federal payment recipients who owe a delinquent debt. Providing 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 U.S. Department of Justice only in accordance with
the provisions of the Privacy Act, including the routine uses indicated below:
(a) To the Department of the Treasury to ensure that any recipients of federal payments who also owe
delinquent federal debts have their payment offset or withheld or reduced to satisfy the debt.
(b) 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 – the relevant records may be referred 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.
(c) In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the
U.S. 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.
(d) 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.
(e) To the news media and the public, including disclosures pursuant to 28 C.F.R. § 50.2, unless it is determined
that release of the specific information in the context of a particular case would constitute an unwarranted
invasion of personal privacy.
(f) 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 this system of records.
(g) To a former employee of the U.S. Department of Justice for purposes of: responding to an official inquiry by
a federal, state, or local government entity or professional licensing authority, in accordance with applicable U.S.
Department of Justice regulations; or facilitating communications with a former employee that may be
necessary for personnel-related or other official purposes where the U.S. Department of Justice requires
information and/or consultation assistance from the former employee regarding a matter within that person’s
former area of responsibility.
(h) 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.
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(i) To appropriate agencies, entities, and persons when (1) the U.S. Department of Justice suspects or has
confirmed that the security or confidentiality of information in the system of records has been compromised; (2)
the U.S. Department of Justice has determined that as a result of the suspected or confirmed compromise there
is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of
this system or other systems or programs (whether maintained by the U.S. Department of Justice or another
agency or entity) that rely upon the compromised information; and (3) the disclosure made to such agencies,
entities, and persons is reasonably necessary to assist in connection with the U.S. Department of Justice’s efforts
to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.
(j) 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.
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 Office of Management and Budget (“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. The information
collected in this Application Form 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. It is estimated that applicants will
complete the Application Form in an average of 2 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. Victims of State Sponsored Terrorism Fund, U.S. Department of Justice, 950
Pennsylvania Ave, NW, Washington, DC 20530; OMB control number 1123-0013.
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PART I – VICTIM AND APPLICANT INFORMATION
The term “Victim” refers to a U.S. person who (1) has secured a final judgment in a U.S. 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. Please Note: If you are a Personal Representative who is filing on behalf of a
deceased Victim, please complete the below information to the extent possible for the deceased Victim.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Home Phone
Cell Phone
Country (if not in U.S.)
Facsimile
Email Address
Is or was the Victim a U.S. citizen?
Date of Birth
Yes No
Provide the Victim’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any: ____________________
If the Victim does or did not have a SSN or TIN, or is or was not a U.S. citizen, provide the following:
National Identification Number
Country of Citizenship
Passport Number
Did or has the Victim ever gone by any other names (e.g., maiden name)?
If Yes, provide the following:
Last Name
First Name
4
Passport Country
Yes No
Middle Name
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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 6.
For Applicants who are not the Victim: (You must also complete Question 3)
Select one from the list below:
Personal Representative for the deceased Victim. 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. (You must also complete Question 4)
Guardian of a non-minor.
Other (please specify): ______________________________
For Attorneys:
If your client is an Applicant other than the Victim (such as a Personal Representative), please complete
Questions 3 and 6.
If your client is the Victim, you may skip Questions 3 and 4 and provide your information in Question 6.
If there is a co-Personal Representative or if you share joint custody of a minor, you also must provide that individual’s
information in Question 4.
3. Complete the following information for the Applicant:
Last Name
First Name
Middle Name
Mailing Address
City
State
Home Phone
Cell Phone
Zip/Postal Code
Country (if not in U.S.)
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
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4. If applicable, complete the following information about the person with whom you share joint representation
or custody of the Victim. Please Note: Both signatures are required wherever the Fund asks for a signature.
Not Applicable
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Home Phone
Cell Phone
Country (if not in U.S.)
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 ALTERNATIVE CONTACT (IF APPLICABLE)
5. If there is someone with whom you would like to authorize the Fund to communicate regarding the claim,
(e.g., a spouse or a child), list his or her contact information below.
Not Applicable
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Country (if not in U.S.)
Email Address
Telephone
Relationship to the Victim
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INFORMATION ABOUT THE APPLICANT’S ATTORNEY (IF APPLICABLE)
6. If an attorney is representing the Applicant with this claim, fill out the information below:
Please Note: All communications from the Fund will be with the attorney you identify unless your attorney
instructs the Fund 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. A separate Application Form must be completed and filed on behalf
of each represented individual.
Not Applicable
Last Name
First Name
Middle Name
Law Firm Name
Mailing Address
City
Email Address
State
Zip/Postal Code
Telephone
7
Country (if not in U.S.)
Facsimile
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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 Part II.B
below and provide the appropriate supporting documents, as applicable. Part VI 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 U.S. district
court under state or federal law, awarding the Victim compensatory damages on a claim(s) brought by the Victim
arising from acts of international terrorism for which the foreign state was found not immune from the jurisdiction of
the courts of the United States under the 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 Part VI of the Fund’s Notice published in the Federal Register and available on the Fund’s
website www.usvsst.com. In addition, a Victim seeking a conditional payment must sign the certification in Part
IV of the Application Form.
HOLDER OF A FINAL JUDGMENT
7. Please provide the name of the case, the U.S. district court in which the judgment was entered, the case
number, and the amount of compensatory damages awarded.
Case Name
U.S. District Court
Case Number
Compensatory Damages Award Amount
8. Were any immediate family member(s) of the Victim identified in the final judgment?
If No, proceed to Question 10.
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Yes No
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9. List any immediate family member(s) who also were identified in the final judgment. Immediate family
members are a spouse, domestic partner, child, stepchild, parent, stepparent, brother, sister, half-brother,
and half-sister of the Victim. If more than two immediate family members were identified in the final
judgment, identify each family member by copying this page, completing this section for each one, and
submitting the additional page(s) with the Application Form.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Relationship to the Victim
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Relationship to the Victim
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10. Did any immediate family member(s) obtain any separate final judgment(s) based on the same act of
international terrorism? Yes No
Answer the questions below only if you answered yes to Question 10. If more than one immediate
family member was identified in the(se) final judgment(s), identify each family member by copying
this page, completing this section for each one, and submitting the additional page(s) with the
Application Form.
a) If Yes, please list the immediate family member(s) who obtained the separate final judgment(s).
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Relationship to the Victim
b) Please provide the name of the case, the U.S. district court in which the separate final judgment was
entered, the case number, and the amount of compensatory damages awarded.
Case Name
U.S. District Court
Case Number
Compensatory Damages Award Amount
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11. 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 11.
a) Please indicate whether the Victim is a judgment creditor, Settling Judgment Creditor, or both.
Judgment creditor in Peterson v. Islamic Republic of Iran
Settling Judgment Creditor in In re 650 Fifth Avenue & Related Properties
Both a judgment creditor in Peterson v. Islamic Republic of Iran and a Settling Judgment Creditor
in In re 650 Fifth Avenue & Related Properties
b) Is the Victim electing to participate in the Fund? Yes No
Answer the questions below only if you answered yes to Question 11b.
i)
Did the Victim separately notify the Attorney General in writing? Yes No
Date the Attorney General was notified: ________________________
ii) Did the Victim separately notify the chief judge of the United States District Court for the
Southern District of New York? Yes No
Date the chief judge was notified: ________________________
iii) Did the Victim separately notify the Special Master in writing? Yes No
Date the Special Master was notified: ________________________
Answer the question below only if you answered no to Question 11b.
iv) Is the Victim seeking a Conditional Payment? Yes No
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12. Did the Victim or the Victim’s Personal Representative file a claim with the September 11 th Victim
Compensation Fund of 2001? Yes No
Answer the questions below only if you answered yes to Question 12.
a) Did the Victim receive an award or an award determination (including a determination that denied
an award)? Yes No
b) Did the Victim’s heirs and beneficiaries receive an award or an award determination? Yes No
Answer the question below only if you answered yes to Question 12(b).
Please identify the heirs and beneficiaries who received an award or an award determination from
the September 11th Victim Compensation Fund of 2001. If more than two heirs and beneficiaries
received an award or an award determination, identify each heir and beneficiary by copying this
page, completing this section for each one, and submitting the additional page(s) with the
Application Form.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Relationship to the Victim
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Relationship to the Victim
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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 the Victim 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 is 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
13. Date the Victim was taken hostage:
___________________
14. Date the Victim was released:
___________________
15. 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
16. Name of hostage:
___________________
17. Date the spouse was married to the former hostage:
___________________
18. Did the marriage continue through January 20, 1981?
Yes No
19. 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
20. Name of hostage:
___________________
21. Date of birth:
___________________
22. Was the child adopted by the former hostage?
Yes No
If Yes, date of adoption:
___________________
23. 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
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PART III – OTHER INFORMATION IN SUPPORT OF APPLICATION
COMPENSATION SOURCES OTHER THAN THIS FUND
All Applicants (except those applying as Iran hostages, or spouses or children thereof) 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 11th Victim
Compensation Fund of 2001); and court awarded compensation related to the act that gave rise to the judgment.
24. Indicate below whether the Victim or the Victim’s beneficiaries received or is entitled to receive any of the
following:
Program/Benefits
Y/N
Amount
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
Any other source(s) of compensation not
already listed
(If any, please provide the type and source
in the “Source(s)” column)
Yes No
Source(s)
If more space is required for other sources of compensation, identify each source by copying this page and submitting
the additional page(s) with the Application Form.
Please Note: It is the Applicant’s obligation to keep the Fund informed 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.
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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 related funds deposited in the Fund if the
other conditions in 42 U.S.C. § 10609(g) are met.
Not Applicable
25. Has the Victim or Applicant notified the Attorney General?
Yes No
a) If Yes, please provide the date of the communication and identify the person notified:
________________________________________________________________________________________
________________________________________________________________________________________
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 may be relevant.
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PART IV – SIGNATURES AND CERTIFICATIONS
By submitting this Application Form, you are agreeing that you understand the notices below (continued on the
following page), including the Privacy Act (as referenced fully in the instructions), authorization to communicate with
your attorney or other representative, and the limitation on attorneys’ fees.
Instructions: Please review the following statements and initial where indicated. Sign, date, and print your name at the
end of the Application Form.
For all Applicants, please initial in acknowledgement of the following:
_________
Applicant
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 Form 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. When a Victim is represented by a third party, such
as a Victim’s legal guardian, the Personal Representative of the decedent Victim’s estate, or other
person legally authorized to act for the Victim, these persons must have authority to certify on behalf of
the Victim.
_________
Applicant
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 title 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.
_________
Applicant
Initials
I authorize the U.S. Department of Justice to disclose any records or information relating to my claim in
accordance with the Privacy Act Notice, including the routine uses, identified above. This includes, but is
not limited to, the disclosure of any records or information relating to my claim for the purpose of
determining qualification and/or compensation of my claim specifically to: agency contractors
performing or working on a contract, service, grant, cooperative agreement, or other assignment for the
federal government when necessary for administration of the Fund; and the Department of the Treasury
to ensure that any recipients of federal payments who also owe delinquent debts have their payment
offset or withheld or reduced to satisfy the debt.
_________
Applicant
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 assignees) 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 U.S. district court pursuant to a judgment.
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For Applicants who are represented by an attorney, you and your attorney must initial the following:
_________
Applicant
Initials
_________
Attorney
Initials
Notwithstanding any contract for legal services or retainer agreement, 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 a Settling Judgment
Creditor in In re 650 Fifth Avenue & Related Properties seeking conditional payment, please initial the following:
_________
Applicant
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:
_________
Applicant
Initials
I authorize the Special Master, the Special Master’s designees, the U.S. Department of Justice, or agency
contractors assisting in the administration of the Fund to contact my attorney or other persons
authorized to act on my behalf.
For Applicants filing on behalf of a deceased Victim, please initial in acknowledgment of the following:
_________
Applicant
Initials
I certify that I have provided the required Notice of Filing 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
_______________________________
Date of Signature (mm/dd/yyyy)
______________________________________________________
Print Name
______________________________________________________
Signature of Authorized Representative (if applicable)
______________________________________________________
Print Name
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_______________________________
Date of Signature (mm/dd/yyyy)
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
PART V - ADDITIONAL INFORMATION FOR CLAIM FILED FOR DECEASED VICTIMS
This part is for Applicants who are filing a claim on behalf of a deceased Victim.
1. Have you been appointed by a court as the Personal Representative for the deceased Victim?
Yes No
If No, have you attempted to be appointed the Personal Representative by a court?
Yes No
If Yes, explain below 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 Victim 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 Victim:
The immediate family of the decedent (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 “Additional Forms” page of the Fund’s website contains a sample Notice of Filing Claim that you may provide to the
required individuals. You are required to provide notice to everyone in the four categories above, even if they are not
included in the decedent Victim’s will, in accordance with Part VII of the Fund’s Notice published in the Federal Register
and available on the Fund’s website at www.usvsst.com.
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U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
Please complete the information in the following sections:
A. 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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
B. 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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
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U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
C. 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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
D. 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:
If the decedent Victim had more than one former spouse, identify each by copying this page, completing a
section for each spouse, and submitting the additional page(s) with the Application Form.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
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U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
E. Did decedent have siblings?
Yes No
If Yes, indicate how many siblings the decedent Victim had, including siblings who are deceased: _____________
Complete the information below for each sibling.
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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
If the decedent Victim had more than two siblings, identify each sibling by copying this page, completing a
section for each sibling, and submitting the additional page(s) with the Application Form.
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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
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U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
F. 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.
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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
If the decedent Victim had more than two dependents, identify each dependent by copying this page,
completing a section for each dependent, and submitting the additional page(s) with the Application Form.
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
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
22
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
G. Are there any other potential beneficiaries or persons who may have an interest in the claim?
Yes No
If Yes, indicate the number of potential beneficiaries or persons who may have an interest in the claim, including
potential beneficiaries who are deceased: __________
Potential Beneficiary 1 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Relationship to Victim
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not in U.S.)
Telephone
Describe interest in claim
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
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U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
If the decedent Victim had more than two potential beneficiaries, identify each potential beneficiary by copying
this page, completing a section for each potential beneficiary, and submitting the additional page(s) with the
Application Form.
Potential Beneficiary 2 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Relationship to Victim
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not in U.S.)
Telephone
Describe interest in claim
Method of Delivery:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if service could not be completed:
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U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
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 Form is processed quickly. All documents you submit to establish eligibility will be reviewed and
considered by the Special Master.
All documents submitted in languages other than English must be accompanied by a complete translation into English.
In addition, you must include a certification from the translator that he or she is a competent translator and that the
translation is complete and accurate. The certification must include the date and the translator’s name, signature, and
address.
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 Form. Applicants do not need to submit multiple
copies of the same document. One document may satisfy several of the below requirements.
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?
1. A copy of the final judgment. Please Note: You should include all court
documents demonstrating that the judgment qualifies as an eligible final
judgment (e.g., action brought under the FSIA, award for compensatory
damages, and the individual award amount).
2. Proof of service of judgment.
25
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
An Applicant who seeks to establish eligibility for payment as a U.S. person who was held hostage at the U.S. Embassy 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?
1. Verification of the date on which the Victim was taken hostage from the U.S.
Embassy in Tehran, Iran.
2. Verification of the date on which the Victim was released from the U.S.
Embassy in Tehran, Iran.
3. 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 for the District of
Columbia.
An Applicant who seeks to establish eligibility for payment as the spouse of a U.S. person who was held hostage at the
U.S. Embassy 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?
1. A copy of a marriage certificate showing the date of marriage.
2. An affirmation that the marriage continued through January 20, 1981.
3. A copy of the divorce decree, if the Applicant is no longer married to the Victim.
4. 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 for the District of
Columbia.
An Applicant who seeks to establish eligibility for payment as the child of a U.S. person who was held hostage at the U.S.
Embassy 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?
1. A copy of a birth certificate or adoption decree showing a date of birth or
adoption prior to January 20, 1981.
2. 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 for the District of
Columbia.
26
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX
An Applicant who is electing to participate in the Fund as a judgment creditor in Peterson v. Islamic Republic of Iran or a
Settling Judgment Creditor in In re 650 Fifth Avenue & Related Properties, must submit:
Attached?
1. Verification that the judgment holder is a judgment creditor in Peterson v.
Islamic Republic of Iran or a Settling Judgment Creditor in In re 650 Fifth Avenue
& Related Properties.
2. Proof that the Applicant submitted written notice of his or her election to
participate in the Fund by September 12, 2016 to the Attorney General of the
United States, the Special Master, and the chief judge of the United States
District Court for the Southern District of New York.
DOCUMENT REQUIREMENTS FOR PERSONAL 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?
1. Personal Representative of deceased Victim: Copies of legal documentation
showing sufficient evidence of authority to represent the estate of a decedent
Victim, 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.
2. 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.
3. 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 REQUIREMENT FOR APPLICANTS AND VICTIMS REPRESENTED BY AN ATTORNEY
Attached?
1. 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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| File Type | application/pdf |
| File Modified | 2016-10-06 |
| File Created | 2016-10-06 |