Proposed Distribution Plan

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

Name of Applicant (Personal Representative)

Claim Number

Name of Decedent Victim

VICTIM’S WILL AND PROPOSED DISTRIBUTION PLAN INFORMATION
Did the Victim leave a will?

Yes No

If “Yes”, has the will been probated?

Yes No

Do not know

If the Victim left a will, please list the beneficiaries of the Victim’s will.
Beneficiary Name
(Last, First, Middle)

Please provide the requested information below on how you, as the authorized Personal Representative, propose to distribute the
eligible claim amount. In order for the U.S. Victims of State Sponsored Terrorism Fund (the “Fund”) to make a payment, all legal
heirs and beneficiaries must consent to participation in the Fund. You must provide the legal heirs and beneficiaries a copy of the
Proposed Distribution Plan and all legal heirs and beneficiaries must agree to the Proposed Distribution Plan.
If an allocation agreement about the Proposed Distribution Plan cannot be reached by all legal heirs and beneficiaries, the Special
Master may deposit the amount of the award with a court of appropriate jurisdiction to adjudicate the distribution.

Claim Form for Deceased Victim Only

Page 1

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

Relationship
to Victim

Name and Address

Telephone Number

Social Security/ National
Identification/ Other Tax
Identification Number

Spouse

-

-

Former Spouse

-

-

Registered
Domestic
Partner

-

-

Child

-

-

Child

-

-

Mother

-

-

Father

-

-

Sibling

-

-

Sibling

-

-

Other
(specify)

-

-

Claim Form for Deceased Victim Only

% of Award

Page 2

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



Note: Check this box if more space is needed to answer and list additional information on another copy of this page.

_________________________________________________________
Signature of Personal Representative
(the individual named in Part V of the Application Form)

/
/
Date (mm/dd/yyyy)

_________________________________________________________
Printed Name of Personal Representative

Claim Form for Deceased Victim Only

Page 3