Instructions for Changing or Removing Attorney Listed on an Application Form

U.S. Victims Of State Sponsored Terrorism Fund
Instructions for Changing or Removing the Attorney(s)
Listed on an Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX

If you previously authorized the U.S. Victims of State Sponsored Terrorism Fund (the “Fund”) to
communicate with an attorney or attorneys and you now want to revoke this authorization because the
attorney(s) no longer represents you, please submit in writing a letter by either mail, fax, or email (as a
PDF attachment) to the appropriate address below, so we can update the information in your Application
Form. You must sign your letter.
By mail:
U.S. Victims of State Sponsored Terrorism Fund
c/o GCG
PO BOX 10299
Dublin, OH 43017-5899

By fax:
(855) 409-7130 (If outside the U.S., (614) 553-1426)
By email:
[email protected]

If you would like to authorize the Fund to communicate with a new attorney, you will also need to complete
and submit the following documents with that attorney’s information:




Applicant’s/Personal Representative’s Acknowledgement of Attorney’s Compliance with Statutory
Limitation on Attorneys’ Fees
Applicant’s/Personal Representative’s Authorization for Communication and Correspondence
Attorney’s Certification of Compliance with Statutory Limitation on Attorneys’ Fees (to be completed
by your attorney)

If you submitted documents directing the Fund to pay your claim through your attorney, that instruction may
not be changed after the Fund issues you the payment distribution decision. You may still remove or change
the attorney associated with your claim for any future Fund actions and communications, if applicable.

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U.S. Victims Of State Sponsored Terrorism Fund
Instructions for Changing or Removing the Attorney(s)
Listed on an Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX

PAYMENT INSTRUCTIONS FORM – CHANGE OR DISMISSAL OF ATTORNEY
You should use this form if you previously authorized the Fund to make the payments on your claim to an
attorney’s or a law firm’s bank account and you want to change the payment instructions. Read the
information on page 1 and follow the steps below to change the instructions for any payments on your claim.
All forms are available on the Fund’s website at www.usvsst.com under “Additional Forms.”
1. Determine which scenario in Section 1 applies to you and follow the instructions for that scenario.
2. Complete the information in Section 2.
3. Please return this form to the Fund in one of the following ways:





As an email attachment to [email protected]
By facsimile to (614) 553-1426
By U.S. mail to U.S. Victims of State Sponsored Terrorism Fund, c/o GCG, P.O. Box 10299,
Dublin, OH 43017-5899
By overnight courier to U.S. Victims of State Sponsored Terrorism Fund, c/o GCG, 5151 Blazer
Parkway, Dublin, OH 43017-5899

Once the Fund receives this form and the required information, it will process your request and change the
payment instructions for your claim. The Fund will also notify your prior attorney that you have made a
change to your Application Form.





SECTION 1
Scenario A. If you have decided to continue your application yourself without an attorney, you must
return this form with a completed ACH Payment Information Form with the new bank account
information to be used for your Fund payments.
- OR Scenario B. If you are using a new attorney, your new attorney must return this form with all of the
following completed forms:

 ACH Payment Information Form for the law firm (if not already on file with the Fund)
 Applicant’s/Personal Representative’s Acknowledgment of Attorney’s Compliance with
Statutory Limitation on Attorneys’ Fees

 Applicant’s/Personal Representative’s Authorization for Communication and Correspondence
 Attorney’s Certification of Compliance with Statutory Limitation on Attorneys’ Fees (to be
signed by your attorney)

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U.S. Victims Of State Sponsored Terrorism Fund
Instructions for Changing or Removing the Attorney(s)
Listed on an Application Form
OMB No. 1123-0013
Expires XX/XX/XXXX

SECTION 2
Name of Applicant

Claim Number

1. I am changing my instructions to the Fund on how I will receive payments for my claim.
2. I understand that this change does not affect any retainer or other agreement I have with my former
attorney or any obligations I have to pay my former attorney for fees and expenses.

_________________________________
Signature of Applicant

____________________
Date of Signature
(mm/dd/yyyy)

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