Attorney’s Certification of Compliance with Statutory Limitation on Attorneys’ Fees for Personal Representatives

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

Name of Applicant (Personal Representative)

Claim Number (if available)

Name of Decedent Victim

If the Personal Representative is represented by an attorney for services rendered in connection
with this claim submitted to the U.S. Victims of State Sponsored Terrorism Fund, the Personal
Representative’s attorney must complete the following certification.
I hereby certify that:
The amount I charge for the services I have rendered in connection with this claim,
including fees and costs that if aggregated, did not, does not, and will not exceed
25 percent of any resulting payment made under the Justice for U.S. Victims of State
Sponsored Terrorism Act on this claim.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this _____ day of ________________, 20___
____________________________
Signature of Attorney

Last Name

First Name

Middle Name

Law Firm Name

Mailing Address

City

Email Address

State

Zip/Postal Code

Telephone

Country (if not in U.S.)

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