Consent to Proposed Distribution Plan

U.S. Victims of State Sponsored Terrorism Fund
Consent to Proposed Distribution Plan
OMB No. 1123-0013
Expires XX/XX/XXXX

Attached is the Proposed Distribution Plan submitted for compensation from the U.S. Victims of State
Sponsored Terrorism Fund for the claim submitted on behalf of ______________________________ (insert
name of decedent Victim). By signing this Consent to Proposed Distribution Plan you agree to the allocation
set forth in it.
Note: If any dispute exists over the terms of the Proposed Distribution Plan which cannot be resolved by the
parties, the Special Master may deposit the eligible claim amount with a court of appropriate jurisdiction to
adjudicate the distribution.

Claim Number: ________________________

Printed Name of Heir/Beneficiary:

Signature of Heir/Beneficiary:

Date:
(mm/dd/yyyy)