Applicant’s Authorization for Communication and Correspondence

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

If an Applicant (or authorized representative of the Applicant) 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 Applicant

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.