List of Individuals Notified of Claim Filing

U.S. Victims of State Sponsored Terrorism Fund
List of Individuals Notified of Claim Filing
OMB No. 1123-0013
Expires XX/XX/XXXX
You are required to identify all living relatives and potentially interested parties to whom you sent a Notice of Filing Claim. This
form includes fields to provide information about the most common individuals who must be notified about the claim.
Complete the applicable sections below. Be sure to include for each individual the method of delivery and the date the Notice of
Filing Claim was delivered. If a particular individual is deceased, select “DECEASED” and provide only that individual’s name. If
the decedent Victim did not have a particular type of relative or other interested party, note that by selecting “NOT APPLICABLE.”
You must account for all living relatives and potentially interested parties, regardless of whether or not they are included in the
Proposed Distribution Plan.
Certification:
I hereby certify that I have provided the required Notice of Filing Claim to all the individuals listed below by either personal delivery
or certified mail, return receipt requested, and that I am not aware of anyone else to whom such notice should be provided. If notice
was not provided to a particular individual that should be notified about the claim, please provide an explanation on an attached
additional page.
________________________________________
Name of the Personal Representative/Applicant

Claim Number (if applicable): _______________

________________________________________
Signature of Personal Representative/Applicant

Date (mm/dd/yyyy): _ _ /_ _ /_ _ _ _

Relationship to Decedent Victim
Mother:

Deceased (only name required)

Last Name

First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Father:

Deceased (only name required)

Last Name

First Name

Middle Name

Mailing Address
City

State

Date of Birth

Zip/Postal Code

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

U.S. Victims Of State Sponsored Terrorism Fund
List of Individuals Notified of Claim Filing
OMB No. 1123-0013
Expires XX/XX/XXXX

Spouse:

Deceased (only name required)

Last Name

Not Applicable
First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Former Spouse:

Deceased (only name required)

Last Name

Not Applicable

First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Sibling:

Deceased (only name required)

Last Name

Not Applicable
First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

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U.S. Victims Of State Sponsored Terrorism Fund
List of Individuals Notified of Claim Filing
OMB No. 1123-0013
Expires XX/XX/XXXX

Sibling:

Deceased (only name required)

Last Name

Not Applicable
First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Child:

Deceased (only name required)

Last Name

Not Applicable
First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Child:

Deceased (only name required)

Last Name

Not Applicable
First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

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U.S. Victims Of State Sponsored Terrorism Fund
List of Individuals Notified of Claim Filing
OMB No. 1123-0013
Expires XX/XX/XXXX

Partner:

Deceased (only name required)

Last Name

Not Applicable
First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Other:

Deceased (only name required)

Not Applicable

Please describe:
Last Name

First Name

Middle Name

Mailing Address
City

State

Zip/Postal Code

Date of Birth

Country (if not in U.S.)

Telephone

SSN or National ID No. (if available)
Method of Delivery:

 Hand Delivered  Certified Mail, Return Receipt Requested  Other (Describe) ____________________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if service could not be completed:

Indicate here the number of additional pages submitted because you need more space.

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