Hearing Request Form

U.S. Victims of State Sponsored Terrorism Fund
Hearing Request Form
OMB No. 1123-0013
Expires XX/XX/XXXX

If you are represented by an attorney, please consult with your attorney before returning this form. It is important that
only one form be returned to the U.S. Victims of State Sponsored Terrorism Fund (the “USVSST Fund”) to ensure
appropriate action is taken on your claim.

Name of Applicant

Claim Number

I request a hearing of the Special Master’s determination of my claim. If you are requesting a hearing on the
Special Master’s written decision finding your claim not eligible in whole or in part, you must complete this
form and the Pre-Hearing Questionnaire and return them in their entirety to the USVSST Fund. Once you
submit these documents, and the USVSST Fund grants a request for a hearing, the USVSST Fund will contact
you with details about your hearing.

_______________________________________
Applicant Signature

________________________
Date

_______________________________________
Attorney Signature

________________________
Date

PRE-HEARING QUESTIONNAIRE
Section 1
Indicate which portion(s) of your claim you believe was/were not properly decided. Please be as detailed as possible to
enable the USVSST Fund to fully prepare for your hearing. You may include additional pages if you require more space.

Section 2
Who, if anyone, will be participating at the hearing on your behalf and what is each participant’s contact information?
It is your responsibility to request and arrange this participation and to notify the participants of the hearing. The USVSST
Fund may establish procedures for attendance and participation in hearings, but the Fund cannot arrange for any participation
other than USVSST Fund officials.
Full Name

Relationship to Claimant and Purpose
of Participation at the Hearing

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Contact Information
(Address, telephone number, and e-mail address)

U.S. Victims of State Sponsored Terrorism Fund
Hearing Request Form
OMB No. 1123-0013
Expires XX/XX/XXXX

Do you have any special needs or requirements specific to your hearing? Please note that the USVSST Fund does not
provide interpreters for hearings. You are welcome to have someone assist you.

If you have additional documentation you have not submitted to the USVSST Fund that you want to use at your hearing,
you should submit a copy of the documentation with this form. Please identify the additional documentation here (and on
additional pages if necessary) in addition to submitting copies.

Please return the completed form to the USVSST 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

If you have any questions regarding this Hearing Request Form, please email the USVSST Fund at [email protected] or call
the toll-free helpline at (855) 720-6966. If you are calling from outside the U.S., please call (614) 553-1013.
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