Applicant’s Acknowledgment of Attorney’s Compliance with Statutory Limitation on Attorneys’ Fees

U.S. Victims of State Sponsored Terrorism Fund
Applicant’s Acknowledgment of Attorney’s
Compliance with Statutory Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires XX/XX/XXXX

Name of Applicant

Claim Number (if available)

If the Applicant is represented by an attorney for services rendered in connection with his or her claim
submitted to the U.S. Victims of State Sponsored Terrorism Fund, the Applicant must sign and date
the following acknowledgement.
I hereby acknowledge that:
Notwithstanding any contract for legal services or retainer agreement, an attorney representing
an Applicant 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 resulting payment
made under the Justice for U.S. Victims of State Sponsored Terrorism Act on such claim. The
attorney shall certify his or her compliance with this section. 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.

_____________________________________________________
Signature of Applicant

___________________________
Date of Signature
(mm/dd/yyyy)