Download:
pdf |
pdfU.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
Instructions:
Please completely answer the questions in this Application Form (the “Application Form”) as your submission of
a claim for compensation from the U.S. Victims of State Sponsored Terrorism Fund (the “Fund”). If you wish to submit a
claim to the Fund, you must either complete this Application Form or submit an Application Form electronically by visiting
www.usvsst.com. Only one Application Form may be submitted for each claim and only the Personal Representative may
submit a claim for a deceased Victim.
When completing this Application Form, you must:
•
•
•
•
Print your answers using black or blue ink.
Submit your answers in English.
Submit the signed Signature Page with your completed Application Form.
Submit required documentation with your completed Application Form.
The Fund keeps all documents you submit with your Application Form. Please make copies for your records of any
documents you submit, including a copy of your completed Application Form.
Filing Deadline:
A claim based on a final judgment obtained on or after July 14, 2016 must be submitted no later than 90 days
after the date of obtaining the final judgment, unless otherwise specified in the United States Victims of State Sponsored
Terrorism Fund Clarification Act.
Required Documentation Checklist:
A document checklist is provided in Part VI of the Application Form to assist you in gathering and submitting the
document(s) needed to process your claim.
Submitting Your Application Form:
Your completed Application Form may be mailed to the Claims Administrator via first-class or overnight mail,
postage prepaid, addressed as follows:
By regular mail:
U.S. Victims of State Sponsored Terrorism Fund
c/o EPIQ
PO Box 10299
Dublin, OH 43017-5899
By overnight mail:
U.S. Victims of State Sponsored Terrorism Fund
c/o EPIQ
5151 Blazer Parkway, Suite A
Dublin, OH 43017
An Application Form may also be submitted as an email attachment to [email protected] or faxed toll-free to
(855) 409-7130. If you are outside the United States, the collect fax number is +1 (614) 553-1426.
It is very important that you keep the Fund informed of any changes in your mailing address, telephone number,
or email address because the Fund will use that information to contact you about your claim.
If you need assistance completing this Application Form, or have any questions, please call our toll-free helpline
at (855) 720-6966. If you are calling from outside the United States, please call collect at +1 (614) 553-1013.
1
November 2019
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
Privacy Act Notice:
By submitting this Application Form, you are authorizing the U.S. Department of Justice to collect this information as
allowed by the Justice for United States Victims of State Sponsored Terrorism Act (the “Act”), codified at 34 U.S.C. § 20144
(formerly 42 U.S.C. § 10609). The information you submit in your claim, including but not limited to your Social Security
Number, is for official use by the U.S. Department of Justice for the purposes of determining your eligibility for, and the
amount of, compensation you may receive under your claim to the Fund. In addition, Executive Order 9397
(November 22, 1943) authorizes federal agencies to use Social Security numbers as individual identifiers to distinguish
between people with the same or similar names, and 5 U.S.C. § 5514, 26 U.S.C. §§ 6402, 6331, 31 U.S.C. §§ 3711-20E,
42 U.S.C. § 664, and other applicable legal authorities, authorize the Department of the Treasury and other officials
disbursing federal payments to use individual Social Security numbers to identify federal payment recipients who owe a
delinquent debt. Providing this information is voluntary; however, failure to provide complete information may result in
a delay in processing or a denial of your claim. Information you submit regarding your claim may be disclosed by the U.S.
Department of Justice only in accordance with the provisions of the Privacy Act, including the routine uses indicated below:
(a) To the Department of the Treasury to ensure that any recipients of federal payments who also owe delinquent
federal debts have their payment offset or withheld or reduced to satisfy the debt.
(b) Where a record, either alone or in conjunction with other information, indicates a violation or potential
violation of law – criminal, civil, or regulatory in nature – the relevant records may be referred to the
appropriate federal, state, local, territorial, tribal, or foreign law enforcement authority or other appropriate
entity charged with the responsibility for investigating or prosecuting such violation or charged with enforcing
or implementing such law.
(c) In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the U.S.
Department of Justice determines that the records are arguably relevant to the proceeding; or in an
appropriate proceeding before an administrative or adjudicative body when the adjudicator determines the
records to be relevant to the proceeding.
(d) To an actual or potential party to litigation or the party’s authorized representative for the purpose of
negotiation or discussion of such matters as settlement, plea bargaining, or in informal discovery proceedings.
(e) To the news media and the public, including disclosures pursuant to 28 C.F.R. § 50.2, unless it is determined
that release of the specific information in the context of a particular case would constitute an unwarranted
invasion of personal privacy.
(f) To contractors, grantees, experts, consultants, students, and others performing or working on a contract,
service, grant, cooperative agreement, or other assignment for the federal government, when necessary to
accomplish an agency function related to this system of records.
(g) To a former employee of the U.S. Department of Justice for purposes of: responding to an official inquiry by a
federal, state, or local government entity or professional licensing authority, in accordance with applicable
U.S. Department of Justice regulations; or facilitating communications with a former employee that may be
necessary for personnel-related or other official purposes where the U.S. Department of Justice requires
information and/or consultation assistance from the former employee regarding a matter within that person’s
former area of responsibility.
(h) To a Member of Congress or staff acting upon the Member’s behalf when the Member or staff requests the
information on behalf of, and at the request of, the individual who is the subject of the record.
2
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
(i) To appropriate agencies, entities, and persons when (1) the U.S. Department of Justice suspects or has
confirmed that the security or confidentiality of information in the system of records has been compromised;
(2) the U.S. Department of Justice has determined that as a result of the suspected or confirmed compromise
there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or
integrity of this system or other systems or programs (whether maintained by the U.S. Department of Justice
or another agency or entity) that rely upon the compromised information; and (3) the disclosure made to such
agencies, entities, and persons is reasonably necessary to assist in connection with the U.S. Department of
Justice’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such
harm.
(j) To the National Archives and Records Administration for purposes of records management inspections
conducted under the authority of 44 U.S.C. §§ 2904 and 2906.
(k) To another Federal agency or Federal Entity, when the Department determines that information from this
system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a
suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the
recipient agency or entity (including its information systems, programs, and operations), the Federal
Government, or national security, resulting from a suspected or confirmed breach.
(l) To professional organizations or associations with which individuals covered by this system of records may be
affiliated, such as state bar disciplinary authorities, to meet their responsibilities in connection with the
administration and maintenance of standards of conduct and discipline.
(m) To any agency, organization, or individual for the purpose of performing authorized audit or oversight
operations of the Department and meeting related reporting requirements.
(n) To such recipients and under such circumstances and procedures as are mandated by Federal statute or
treaty.
Paperwork Reduction Act Notice:
This request is in accordance with the Paperwork Reduction Act of 1995. An agency may not conduct or sponsor an
information collection and a person is not required to respond to a collection of information unless it contains a currently
valid Office of Management and Budget (“OMB”) approval number. We try to create forms and instructions that are
accurate, can be easily understood, and that impose the least possible burden on you. The information collected in this
Application Form is for the purpose of determining your eligibility for, and the amount of, compensation you may receive
based on your claim to the Fund. The average estimated time for applicants to complete the Application Form is 1.5 hours.
Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed
to the Office of the Special Master, U.S. Victims of State Sponsored Terrorism Fund, U.S. Department of Justice,
950 Pennsylvania Ave, NW, Washington, DC 20530; OMB control number 1123-0013.
3
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
PART I – VICTIM AND APPLICANT INFORMATION
The term “Victim” refers to a U.S. person who (1) has secured a final judgment in a U.S. district court under state or federal
law against a state sponsor of terrorism and arising from an act of international terrorism, for which the foreign state was
found not immune under section 1605A, or section 1605(a)(7), of title 28, United States Code (Foreign Sovereign
Immunities Act, “FSIA”); (2) was taken and held hostage from the United States Embassy in Tehran, Iran, during the period
beginning November 4, 1979, and ending January 20, 1981, or is the spouse or child of that hostage, if identified as a
member of the proposed class in case number 1:00-CV-03110 (EGS) of the United States District Court for the District of
Columbia; or (3) was taken and held hostage from the United States embassy in Tehran, Iran, during the period beginning
November 4, 1979, and ending January 20, 1981, and who did not have an eligible claim before November 21, 2019. The
term “Applicant” refers to the individual who is filing the claim to seek compensation for the Victim. Individuals who are
filing a claim on their own behalf are both the Applicant and the Victim.
INFORMATION ABOUT THE VICTIM
1. Complete the information below. Please Note: If you are a Personal Representative who is filing on behalf of a
deceased Victim, please complete the information below to the extent possible for the deceased Victim.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Home Phone
Cell Phone
Facsimile
Email Address
Is or was the Victim a U.S. citizen?
Country (if not U.S.)
Date of Birth
Yes No
Provide the Victim’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any: ____________________
If the Victim does not or did not have a SSN or TIN, or is not or was not a U.S. citizen, provide the following:
National Identification Number
Country of Citizenship
Passport Number
Did or has the Victim ever used any other names (e.g., maiden name or nickname)?
If Yes, provide the following:
Last Name
First Name
4
Passport Country
Yes No
Middle Name
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
INFORMATION ABOUT THE APPLICANT
2. In what capacity are you filing the claim? Select one from the list below:
Self – I am the Victim. You do not need to complete the remaining information in this section – skip to
Question 6.
For Applicants who are not the Victim: (You must also complete Question 3)
Select one from the list below:
Personal Representative for the deceased Victim. In addition to completing the applicable sections
below, you must complete Part V of the Application Form.
Parent or guardian of a Victim who is a minor. Please provide additional information below:
I have sole legal custody of the minor.
I share or have joint legal custody of the minor. (You must also complete Question 4)
Guardian of a non-minor.
Other (please specify): ______________________________
For Attorneys:
If your client is an Applicant other than the Victim (such as a Personal Representative), please complete
Questions 3 and 6.
If your client is the Victim, you may skip Questions 3 and 4 and provide your information in Question 6.
If there is a co-Personal Representative or if you share joint custody of a minor, you also must provide that individual’s
information in Question 4.
5
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
3. Complete the following information for the Applicant:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Home Phone
Cell Phone
Facsimile
Email Address
Is the Applicant a U.S. citizen?
Country (if not U.S.)
Date of Birth
Yes No
Provide the Applicant’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any: ____________________
If the Applicant does not have an SSN or TIN, or is not a U.S. citizen, provide the following:
National Identification Number
Country of Citizenship
Passport Number
Passport Country
Did or has the Applicant ever used any other names (e.g., maiden name or nickname)?
If Yes, provide the following:
Last Name
First Name
6
Yes No
Middle Name
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
4. If applicable, complete the following information about the person with whom you share joint representation
or custody of the Victim. Please Note: Both signatures are required wherever the Fund asks for a signature.
Not Applicable
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Home Phone
Cell Phone
Facsimile
Email Address
Is the person a U.S. citizen?
Country (if not U.S.)
Date of Birth
Yes No
Provide the person’s Social Security Number (SSN) or Taxpayer ID Number (TIN), if any: _____________________
If the person does not have an SSN or TIN, or is not a U.S. citizen, provide the following:
National Identification Number Country of Citizenship
Passport Number
Passport Country
Did or has the Applicant ever used any other names (e.g., maiden name or nickname)?
If Yes, provide the following:
Last Name
First Name
7
Yes No
Middle Name
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
INFORMATION ABOUT ALTERNATIVE CONTACT (IF APPLICABLE)
5. If there is someone with whom you would like to authorize the Fund to communicate regarding the claim,
(e.g., a spouse or a child), list his or her contact information below.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Country (if not U.S.)
Email Address
Telephone
Relationship to the Victim
INFORMATION ABOUT THE APPLICANT’S ATTORNEY (IF APPLICABLE)
6. If an attorney is representing the Applicant with this claim, fill out the information below:
Please Note: All communications from the Fund will be with the attorney you identify unless your attorney instructs
the Fund otherwise in writing. In addition, you must provide documentation (signed by you and your attorney) of
your counsel’s authority to represent you, and you and your attorney must complete the certification in Part IV
acknowledging that attorneys may not charge, receive, or collect any payment of fees and costs that in the
aggregate (i) exceed 25% of any payments made on the claim of non-9/11 related victim, or (ii) exceed 15% of any
payments made on the claim of 9/11 related victim. A separate Application Form must be completed and filed on
behalf of each represented individual.
Last Name
First Name
Middle Name
Law Firm Name
Mailing Address
City
Email Address
State
Zip/Postal Code
Telephone
8
Country (if not U.S.)
Facsimile
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
PART II – ELIGIBILITY FOR COMPENSATION
In order for the Victim to receive compensation from the Fund, the Applicant must complete this Part and provide the
appropriate supporting documents, as applicable. Part VI lists the required supporting documents you must submit to
support each claim.
VICTIM WHO IS A HOLDER OF A FINAL JUDGMENT
Check the box below and answer each question if the Victim is the holder of a final judgment issued by a U.S. district
court under state or federal law, awarding the Victim compensatory damages on a claim(s) brought by the Victim arising
from acts of international terrorism for which the foreign state was found not immune from the jurisdiction of the
courts of the United States under the FSIA (“FSIA final judgment”).
HOLDER OF A FINAL JUDGMENT
7. Please provide the name of the case, the U.S. district court in which the final judgment was entered, the case
number, the amount of compensatory damages awarded, the state sponsor(s) of terrorism, and the name of
the individual(s) whose personal injury or death was the basis for the FSIA final judgment.
Case Name
U.S. District Court
Case Number
Compensatory Damages Award Amount
State Sponsor(s) of Terrorism
Name of the individual(s) whose personal injury or death was the
basis for the FSIA final judgment
Questions 8-10 ask you to identify the immediate family members of the individual(s) whose personal injury or death
was the basis for the FSIA final judgment. Immediate family members are a spouse, domestic partner, child,
stepchild, parent, stepparent, brother, sister, half-brother, and half-sister of such individual(s).
Please Note: The Victim’s immediate family members may be different than the immediate family members of the
individual(s) whose personal injury or death was the basis for the FSIA final judgment.
8. Other than the Victim, does the FSIA final judgment identify any immediate family member(s) of the
individual(s) whose personal injury or death was the basis for the final judgment?
Yes No
If No, proceed to Question 10.
9
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
9. List any immediate family member(s) who was/were identified in the FSIA final judgment. If more than two
immediate family members were identified in the final judgment, identify each family member by copying this
page, completing this section for each family member, and submitting the additional page(s) with the
Application Form.
Last Name
First Name
Middle Name
Mailing Address
City
State
Telephone
Relationship to the individual(s) whose personal injury or death was the
basis for the FSIA judgment
Last Name
Zip/Postal Code
First Name
Country (if not in U.S.)
Middle Name
Mailing Address
City
State
Telephone
Relationship to the individual(s) whose personal injury or death was the
basis for the FSIA judgment
Last Name
Zip/Postal Code
First Name
Country (if not in U.S.)
Middle Name
Mailing Address
City
State
Zip/Postal Code
Telephone
Relationship to the individual(s) whose personal injury or death was the
basis for the FSIA judgment
10
Country (if not in U.S.)
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
10. Did any immediate family member(s) obtain any separate final judgment(s) based on the same act of
international terrorism? Yes No
If Yes, complete the information below. If more than one immediate family member was identified in
the(se) final judgment(s), identify each family member by copying this page, completing this section for
each one, and submitting the additional page(s) with the Application Form.
a) List the immediate family member(s) who obtained the separate final judgment(s).
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Country (if not in U.S.)
Telephone
Relationship to the individual(s) whose personal injury or death was the
basis for the FSIA judgment
b) Provide the name of the case, the U.S. district court in which the separate final judgment
was entered, the case number, and the amount of compensatory damages awarded.
Case Name
U.S. District Court
Case Number
Compensatory Damages Award Amount
11
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
11. Is the Victim’s claim related to the acts of international terrorism carried out on September 11, 2001?
Yes No
If Yes, did the Victim or the Victim’s Personal Representative file a claim with the September 11th Victim
Compensation Fund of 2001 under section 405 of the Air Transportation Safety and System Stabilization Act
(49 U.S.C. § 40101)? Yes No
VICTIM WHO WAS HELD HOSTAGE
12. Was the Victim taken and held hostage from the U.S. Embassy in Tehran, Iran, during the period beginning
November 4, 1979, and ending January 20, 1981? Yes No
If Yes, provide the following:
a) Date the Victim was taken hostage:
__________________
b) Date the Victim was released:
__________________
12
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
PART III – OTHER INFORMATION IN SUPPORT OF APPLICATION
COMPENSATION SOURCES OTHER THAN THIS FUND
All Applicants must complete this section. Please identify compensation from any source other than this Fund that the
Victim, or the Victim’s beneficiaries, received or is entitled to receive as a result of the act of international terrorism
that gave rise to his or her final judgment. Sources other than this Fund include, but are not limited to, life insurance;
pension funds; death benefit programs; payments by federal, state, or local governments; and court-awarded
compensation related to the act that gave rise to the judgment.
13. Indicate below whether the Victim or the Victim’s beneficiaries received or is entitled to receive any of the
following:
Program/Benefits
Y/N
Amount
Life insurance
Yes No
Pension funds
Yes No
Death benefit programs
Yes No
Payments by federal, state, or local
governments
Yes No
Court-awarded compensation related to
the act which gave rise to the judgment
Yes No
Any other source(s) of compensation not
already listed
(If any, please provide the type and
source in the “Source(s)” column)
Yes No
Source(s)
If more space is required for other sources of compensation, identify each source by copying this page and submitting
the additional page(s) with the Application Form.
IMPORTANT NOTE: The Applicant MUST keep the Fund informed of any compensation that the Victim, or the Victim’s
beneficiaries, received or is entitled to receive from sources other than this Fund throughout the life of the Fund.
13
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
INFORMER INFORMATION (IF APPLICABLE)
Complete this section only if you are seeking additional compensation as an informer. A Victim who meets the eligibility
requirements of Part II above and identifies and notifies the Attorney General in writing of funds or property of a state
sponsor of terrorism, or held by a third party on behalf of or subject to the control of that state sponsor of terrorism,
may be eligible to receive an award of 10% of the related funds deposited in the Fund if the other conditions in 34 U.S.C.
§ 20144(g) are met.
Not Applicable
14. When did the Victim or Applicant notify the Attorney General?
Please provide the date of the communication and identify the person notified: ________________________________
Please provide a copy of the communication notifying the Attorney General.
ADDITIONAL INFORMATION (Optional)
Use the area below (and any additional pages) to provide any other information that may be relevant to the individual
circumstances of this claim. Please also identify and submit any additional documents not already requested that may
be relevant.
14
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
PART IV – SIGNATURES AND CERTIFICATIONS
By submitting this Application Form, you are agreeing that you understand the notices below (continued on the
following page), including the Privacy Act Notice (as referenced fully in the instructions), authorization to communicate
with your attorney or other representative, and the limitation on attorneys’ fees.
Instructions: Please review the following statements and initial where indicated. Sign, date, and print your name at the
end of the Application Form.
For all Applicants, please initial in acknowledgement of the following:
_________
Applicant
Initials
I certify, under oath, subject to penalty of perjury or in a manner that meets the requirements of title
28 U.S.C. § 1746, that the information provided in the Application Form and any documents submitted
in support of the claim are true and accurate to the best of my knowledge, and I agree that any payment
made by the Fund is expressly conditioned upon the truthfulness and accuracy of the information and
documentation submitted in support of the claim. When a Victim is represented by a third party, such
as a Victim’s legal guardian, the Personal Representative of the deceased Victim’s estate, or other
person legally authorized to act for the Victim, these persons must have authority to certify on behalf
of the Victim.
_________
Applicant
Initials
I understand that false statements or claims made in connection with the claim may result in fines,
imprisonment, and/or any other remedy available by law to the federal government, including as
provided in title 18 U.S.C. § 1001, and that claims that appear to be potentially fraudulent or to contain
false information will be forwarded to federal, state, and local law enforcement authorities for possible
investigation and prosecution.
_________
Applicant
Initials
I authorize the U.S. Department of Justice to disclose any records or information relating to my claim in
accordance with the Privacy Act Notice, including the routine uses, identified above. This includes, but
is not limited to, the disclosure of any records or information relating to my claim for the purpose of
determining qualification and/or compensation of my claim specifically to: agency contractors
performing or working on a contract, service, grant, cooperative agreement, or other assignment for
the federal government when necessary for administration of the Fund; and the Department of the
Treasury to ensure that any recipients of federal payments who also owe delinquent debts have their
payment offset or withheld or reduced to satisfy the debt.
_________
Applicant
Initials
If I receive payment under the Act, I agree and accept that the United States shall be subrogated to the
rights of the Victim (and any of his or her heirs, successors, or assignees) to the extent and in the amount
of such payment, but that, to the extent amounts of damages remain unpaid and outstanding to the
Victim following any payments made under this Act, each Victim shall retain creditor rights in any unpaid
or outstanding amounts of the judgment, including any prejudgment or post-judgment interest, or
punitive damages, awarded by a U.S. district court pursuant to a judgment.
15
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
For Applicants who are represented by an attorney, you and your attorney must initial the following:
_________
Applicant
Initials
_________
Attorney
Initials
_________
Applicant
Initials
_________
Attorney
Initials
For non-9/11 related claims
Notwithstanding any contract for legal services or retainer agreement, an attorney representing a
Victim or an Applicant may not charge, receive, or collect, and the Special Master will not approve,
any payment of fees and costs that in the aggregate exceeds 25 percent of any payment made under
this title on the claim of a non-9/11 related victim. The attorney shall certify his or her compliance
with this section and shall provide such information as the Special Master requires ensuring such
compliance. An attorney who violates this limitation on fees shall be fined under title 18, United
States Code, imprisoned for not more than 1 year, or both.
For 9/11 related claims
Notwithstanding any contract for legal services or retainer agreement, an attorney representing a
Victim or an Applicant may not charge, receive, or collect, and the Special Master will not approve,
any payment of fees and costs that in the aggregate exceeds 15 percent of any payment made under
this title on the claim of a 9/11 related victim. The attorney shall certify his or her compliance with
this section and shall provide such information as the Special Master requires ensuring such
compliance. An attorney who violates this limitation on fees shall be fined under title 18, United
States Code, imprisoned for not more than 1 year, or both.
For Applicants with an attorney or other authorized representative or alternative contact, please initial in
acknowledgment of the following:
_________
Applicant
Initials
I authorize the Special Master, the Special Master’s designees, the U.S. Department of Justice, or agency
contractors assisting in the administration of the Fund to contact my attorney or other persons
authorized to act on my behalf.
For Applicants filing on behalf of a deceased Victim, please initial in acknowledgment of the following:
_________
Applicant
Initials
I certify that I have provided the required Notice of Filing Claim to all of the decedent’s living relatives
and potentially interested parties 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.
______________________________________________________
Signature of Applicant
_______________________________
Date of Signature (mm/dd/yyyy)
______________________________________________________
Print Name
______________________________________________________
Signature of Authorized Representative (if applicable)
______________________________________________________
Print Name
16
_______________________________
Date of Signature (mm/dd/yyyy)
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
PART V - ADDITIONAL INFORMATION FOR CLAIM FILED FOR DECEASED VICTIM
This Part is for Applicants who are filing a claim on behalf of a deceased Victim.
1. Have you been appointed by a court as the Personal Representative for the deceased Victim?
Yes No
If No, have you attempted to be appointed the Personal Representative by a court?
Yes No
Explain below why you either did not seek to be appointed the Personal Representative by the court or were not
appointed as the Personal Representative by a court. You may also attach a statement to your Application Form
with the explanation.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2. Did the deceased Victim leave a will?
Yes No Do Not Know
3. If No, where was the Victim domiciled at the time of death? ___________________________
4. Please provide the Victim’s date of death:
___________________________
NOTICE TO INDIVIDUALS OF FILING OF CLAIM
You are required to notify the following people that you are filing a claim on behalf of the deceased Victim:
The immediate family of the deceased Victim (the spouse, former spouse(s), partner, children, stepchildren, other
dependents, siblings, and parents);
The executor/administrator and beneficiaries of the deceased Victim’s will;
The beneficiaries of the deceased Victim’s life insurance policies; and
Any other person who may reasonably be expected to assert an interest in an award or to have a cause of action
to recover damages relating to the wrongful death of the deceased Victim.
The “Additional Forms” page available on the Fund’s website contains a sample Notice of Filing Claim that you may provide
to the required individuals. You are required to provide notice to everyone in the four categories above, even if they are
not included in the deceased Victim’s will, in accordance with Part VII of the Fund’s Notice published in the Federal Register
and also available on the Fund’s website at www.usvsst.com.
17
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
Please complete the information in the following sections:
A. Deceased Victim’s mother – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
B. Deceased Victim’s father – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
18
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
C. Did deceased Victim have a spouse or partner?
Yes - spouse Yes – partner No
If Yes – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
D. Did deceased Victim have a former spouse or partner?
Yes – former spouse Yes – former partner No
If Yes – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
If the deceased Victim had more than one former spouse, identify each by copying this page, completing a section
for each spouse, and submitting the additional page(s) with the Application Form.
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not in U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
19
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
E. Did deceased Victim have siblings?
Yes No
If Yes, indicate how many siblings the deceased Victim had, including siblings who are deceased: _____________
Complete the information below for each sibling. If the deceased Victim had more than two siblings, identify each
sibling by copying this page, completing a section for each sibling, and submitting the additional page(s) with the
Application Form.
Sibling 1 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
Sibling 2 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
20
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
F. Did deceased Victim have dependents (including biological, adopted, or stepchildren)?
Yes No
If Yes, indicate how many dependents the deceased Victim had, including dependents who are
deceased:__________
Complete the information below for each dependent. If the deceased Victim had more than two dependents,
identify each dependent by copying this page, completing a section for each dependent, and submitting the
additional page(s) with the Application Form.
Dependent 1 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
Dependent 2 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
21
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
G. Are there any other potential beneficiaries or persons who may have an interest in the claim?
Yes No
If Yes, indicate the number of potential beneficiaries or persons who may have an interest in the claim, including
potential beneficiaries who are deceased: __________
If the deceased Victim had more than two potential beneficiaries, identify each potential beneficiary by copying
this page, completing a section for each potential beneficiary, and submitting the additional page(s) with the
Application Form.
Potential Beneficiary 1 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Relationship to Victim
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Describe interest in claim
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Date of Delivery: _ _ / _ _ / _ _ _ _
Other (Describe) ________________________
Please provide a short explanation if delivery could not be completed:
22
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
Potential Beneficiary 2 – this individual is:
Deceased (only name required) Living but address unknown Living and information below:
Last Name
First Name
Middle Name
Relationship to Victim
Mailing Address
City
State
Zip/Postal Code
Email Address
Country (if not U.S.)
Telephone
Describe interest in claim
Method of Delivery of the Notice of Filing Claim:
Hand Delivered Certified Mail, Return Receipt Requested
Other (Describe) ________________________
Date of Delivery: _ _ / _ _ / _ _ _ _
Please provide a short explanation if delivery could not be completed:
23
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
PART VI – DOCUMENT CHECKLIST
You must provide the documentation described below to establish eligibility for payment under the Act. In certain cases,
the Special Master may request additional documentation. Providing thorough documentation is the best way to ensure
your Application Form is processed quickly. All documents you submit to establish eligibility will be reviewed and
considered by the Special Master.
All documents submitted in languages other than English must be accompanied by a complete translation into English. In
addition, you must include a certification from the translator that he or she is a competent translator and that the
translation is complete and accurate. The certification must include the date and the translator’s name, signature, and
address.
Any requests for waiver of a documentation requirement or an extension of time in which to submit a particular document
must be submitted to the Special Master in writing at least 20 business days prior to the application deadline. Decisions
to waive a documentation requirement or to extend the time to submit a particular document are wholly within the
discretion of the Special Master.
You must submit all supporting documentation with your Application Form. Applicants do not need to submit multiple
copies of the same document. One document may satisfy several of the below requirements.
DOCUMENT REQUIREMENTS TO ESTABLISH ELIGIBILITY
An Applicant who seeks to establish eligibility for payment on the basis of a final judgment, as described in Part II above,
must submit:
Attached?
1. A copy of the final judgment. Please Note: You should include all court
documents demonstrating that the judgment qualifies as an eligible final
judgment (e.g., action brought under the FSIA, award for compensatory
damages, and the individual award amount).
2. Proof of service of judgment.
An Applicant who seeks to establish eligibility for payment for a person who was taken and held hostage at the U.S.
Embassy in Tehran, Iran, during the period beginning November 4, 1979, and ending January 20, 1981, must submit:
Attached?
1. Verification of the date on which the Victim was taken hostage from the
United States Embassy in Tehran, Iran, and verification of the date of release.
24
U.S. Victims of State Sponsored Terrorism Fund
Application Form
OMB No. 1123-0013
Expires 12/31/2022
DOCUMENT REQUIREMENTS FOR PERSONAL REPRESENTATIVES
Please Note: In the case of claims brought by a foreign citizen on behalf of a deceased Victim, the Special Master may
alter the document requirements.
Attached?
1. Personal Representative of deceased Victim: Copies of legal documentation
showing sufficient evidence of authority to represent the estate of the
deceased Victim, such as court orders, letters testamentary or similar
documentation, proof of the purported Personal Representative’s relationship
to the deceased Victim, and copies of wills, trusts, or other testamentary
documents.
2. Representative of minor Victim: A copy of a court order or other document
issued by an official showing appointment as the guardian or other authorized
representative of the minor Victim.
3. Representative of non-minor Victim: A copy of a court order or other
document issued by an official showing appointment as the guardian or other
authorized representative of the incompetent Victim.
DOCUMENT REQUIREMENT FOR APPLICANTS AND VICTIMS REPRESENTED BY AN ATTORNEY
Attached?
1. Documentation of counsel’s authority to represent the Applicant, such as a
copy of the retainer agreement or contract for legal services signed by both
the Applicant and the attorney.
DOCUMENT REQUIREMENT FOR APPLICANTS SEEKING ADDITIONAL COMPENSATION AS AN INFORMER
Attached?
1. Copy of the written communication notifying the Attorney General of funds or
property of a state sponsor of terrorism, or held by a third party on behalf of
or subject to the control of that state sponsor of terrorism.
25
U.S. Victims Of State Sponsored Terrorism Fund
Instructions for Changing or Removing the Attorney(s)
Listed on an Application Form
OMB No. 1123-0013
Expires 12/31/2022
If you previously authorized the U.S. Victims of State Sponsored Terrorism Fund (“USVSST Fund”) to
communicate with an attorney or attorneys and you now want to revoke this authorization because the
attorney(s) no longer represents you, please submit in writing a letter by either mail, fax, or email (as a PDF
attachment) to the appropriate address below, so we can update the information in your Application Form.
You must sign your letter.
By mail:
U.S. Victims of State Sponsored Terrorism Fund
c/o Epiq
P.O. Box 10299
Dublin, OH 43017-5899
By fax:
(855) 409-7130 (If outside the U.S., (614) 553-1426)
By email:
[email protected]
If you would like to authorize the USVSST Fund to communicate with a new attorney, you will also need to
complete and submit the following documents with that attorney’s information:
•
•
•
Applicant’s/Personal Representative’s Acknowledgment of Attorney’s Compliance with Statutory
Limitation on Attorneys’ Fees
Applicant’s/Personal Representative’s Authorization for Communication and Correspondence
Attorney’s Certification of Compliance with Statutory Limitation on Attorneys’ Fees (to be completed by
your attorney)
If you submitted documents directing the USVSST Fund to pay your claim through your attorney, that
instruction may not be changed after the USVSST Fund issues you the payment distribution decision. You may
still remove or change the attorney associated with your claim for any future USVSST Fund actions and
communications, if applicable.
1
U.S. Victims Of State Sponsored Terrorism Fund
Instructions for Changing or Removing the Attorney(s)
Listed on an Application Form
OMB No. 1123-0013
Expires 12/31/2022
PAYMENT INSTRUCTIONS FORM – CHANGE OR DISMISSAL OF ATTORNEY
You should use this form if you previously authorized the USVSST Fund to make the payments on your claim
to an attorney’s or a law firm’s bank account and you want to change the payment instructions. Read the
information on page 1 and follow the steps below to change the instructions for any payments on your claim.
All forms are available on the USVSST Fund’s website at www.usvsst.com under “Additional Forms.”
1. Determine which scenario in Section 1 applies to you and follow the instructions for that scenario.
2. Complete the information in Section 2.
3. Please return this 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 Epiq, P.O. Box 10299,
Dublin, OH 43017-5899
By overnight courier to U.S. Victims of State Sponsored Terrorism Fund, c/o Epiq,
5151 Blazer Parkway, Dublin, OH 43017-5899
Once the USVSST Fund receives this form and the required information, it will process your request and change
the payment instructions for your claim. The USVSST Fund will also notify your prior attorney that you have
made a change to your Application Form.
•
•
SECTION 1
Scenario A. If you have decided to continue your application yourself without an attorney, you must
return this form with a completed ACH Payment Information Form with the new bank account
information to be used for your USVSST Fund payments.
- OR Scenario B. If you are using a new attorney, your new attorney must return this form with all of the
following completed forms:
ACH Payment Information Form for the law firm (if not already on file with the USVSST Fund)
Applicant’s/Personal Representative’s Acknowledgment of Attorney’s Compliance with
Statutory Limitation on Attorneys’ Fees
Applicant’s/Personal Representative’s Authorization for Communication and Correspondence
Attorney’s Certification of Compliance with Statutory Limitation on Attorneys’ Fees (to be
signed by your attorney)
2
U.S. Victims Of State Sponsored Terrorism Fund
Instructions for Changing or Removing the Attorney(s)
Listed on an Application Form
OMB No. 1123-0013
Expires 12/31/2022
SECTION 2
Name of Applicant
Claim Number
1. I am changing my instructions to the USVSST Fund on how I will receive payments for my claim.
2. I understand that this change does not affect any retainer or other agreement I have with my former
attorney or any obligations I have to pay my former attorney for fees and expenses.
_________________________________
Signature of Applicant
____________________
Date of Signature
(mm/dd/yyyy)
3
U.S. Victims of State Sponsored Terrorism Fund
Personal Representative’s Authorization For
Communication and Correspondence
OMB No. 1123-0013
Expires 12/31/2022
If a Personal Representative (or authorized representative of the Personal Representative) wants to authorize the
U.S. Victims of State Sponsored Terrorism Fund (“USVSST 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 USVSST Fund to contact the attorney or other person identified
above regarding my claim.
______________________________________________________
_______________________________
Signature of Personal Representative
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.
U.S. Victims of State Sponsored Terrorism Fund
Applicant’s Authorization For
Communication and Correspondence
OMB No. 1123-0013
Expires 12/31/2022
If an Applicant (or authorized representative of the Applicant) wants to authorize the U.S. Victims of State
Sponsored Terrorism Fund (“USVSST 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 USVSST 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.
U.S. Victims of State Sponsored Terrorism Fund
Applicant’s Acknowledgment of Attorney’s
Compliance with Statutory Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant
Claim Number (if available)
If the Applicant is a non-9/11 related victim and is represented by an attorney for services rendered in
connection with his or her claim submitted to the U.S. Victims of State Sponsored Terrorism Fund, the
Applicant must sign and date the following acknowledgment.
I hereby acknowledge that:
Notwithstanding any contract for legal services or retainer agreement, an attorney representing
an Applicant may not charge, receive, or collect, and the Special Master will not approve, any
payment of fees and costs that in the aggregate exceeds 25 percent of any resulting payment
made under the Justice for U.S. Victims of State Sponsored Terrorism Act, amended by the U.S.
Victims of State Sponsored Terrorism Fund Clarification Act, on such claim. The attorney shall
certify his or her compliance with this section. An attorney who violates this limitation on fees
shall be fined under title 18, United States Code, imprisoned for not more than 1 year, or both.
_____________________________________________________
Signature of Applicant
___________________________
Date of Signature
(mm/dd/yyyy)
U.S. Victims of State Sponsored Terrorism Fund
Attorney’s Certification of Compliance with Statutory
Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant
Claim Number (if available)
If the Applicant is a non-9/11 related victim and is represented by an attorney for services rendered
in connection with this claim submitted to the U.S. Victims of State Sponsored Terrorism Fund,
the Applicant’s attorney must complete the following certification.
I hereby certify that:
The amount I charge for the services I have rendered in connection with this claim,
including fees and costs that if aggregated, did not, does not, and will not exceed 25 percent
of any resulting payment made under the Justice for U.S. Victims of State Sponsored
Terrorism Act, amended by the U.S. Victims of State Sponsored Terrorism Fund
Clarification Act, on this claim.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this _____ day of ________________, 20___
____________________________
Signature of Attorney
Last Name
First Name
Middle Name
Law Firm Name
Mailing Address
City
Email Address
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Facsimile
U.S. Victims of State Sponsored Terrorism Fund
Applicant’s Acknowledgment of Attorney’s
Compliance with Statutory Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant
Claim Number (if available)
If the Applicant is a 9/11 related victim and is represented by an attorney for services rendered in
connection with his or her claim submitted to the U.S. Victims of State Sponsored Terrorism Fund, the
Applicant must sign and date the following acknowledgment.
I hereby acknowledge that:
Notwithstanding any contract for legal services or retainer agreement, an attorney representing
an Applicant may not charge, receive, or collect, and the Special Master will not approve, any
payment of fees and costs that in the aggregate exceeds 15 percent of any resulting payment
made under the Justice for U.S. Victims of State Sponsored Terrorism Act, amended by the U.S.
Victims of State Sponsored Terrorism Fund Clarification Act, on such claim. The attorney shall
certify his or her compliance with this section. An attorney who violates this limitation on fees
shall be fined under title 18, United States Code, imprisoned for not more than 1 year, or both.
_____________________________________________________
Signature of Applicant
___________________________
Date of Signature
(mm/dd/yyyy)
U.S. Victims of State Sponsored Terrorism Fund
Attorney’s Certification of Compliance with Statutory
Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant
Claim Number (if available)
If the Applicant is a 9/11 related victim and is represented by an attorney for services rendered in
connection with this claim submitted to the U.S. Victims of State Sponsored Terrorism Fund, the
Applicant’s attorney must complete the following certification.
I hereby certify that:
The amount I charge for the services I have rendered in connection with this claim,
including fees and costs that if aggregated, did not, does not, and will not exceed 15 percent
of any resulting payment made under the Justice for U.S. Victims of State Sponsored
Terrorism Act, amended by the U.S. Victims of State Sponsored Terrorism Fund
Clarification Act, on this claim.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this _____ day of ________________, 20___
____________________________
Signature of Attorney
Last Name
First Name
Middle Name
Law Firm Name
Mailing Address
City
Email Address
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Facsimile
U.S. Victims of State Sponsored Terrorism Fund
Personal Representative’s Acknowledgment of Attorney’s
Compliance with Statutory Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant (Personal Representative)
Claim Number (if available)
Name of Decedent Victim
If the Personal Representative of a 9/11 related victim is represented by an attorney for services
rendered in connection with his or her claim submitted to the U.S. Victims of State Sponsored
Terrorism Fund, the Personal Representative must sign and date the following acknowledgment.
I hereby acknowledge that:
Notwithstanding any contract for legal services or retainer agreement, an attorney representing
a Personal Representative Applicant may not charge, receive, or collect, and the Special Master
will not approve, any payment of fees and costs that in the aggregate exceeds 15 percent of any
resulting payment made under the Justice for U.S. Victims of State Sponsored Terrorism Act,
amended by the U.S. Victims of State Sponsored Terrorism Fund Clarification Act, on this
claim. The attorney shall certify his or her compliance with this section. An attorney who
violates this limitation on fees shall be fined under title 18, United States Code, imprisoned for
not more than 1 year, or both.
_____________________________________________________
Signature of Applicant/Personal Representative
_____________________
Date of Signature
(mm/dd/yyyy)
U.S. Victims of State Sponsored Terrorism Fund
Attorney’s Certification of Compliance with Statutory
Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant (Personal Representative)
Claim Number (if available)
Name of Decedent Victim
If the Personal Representative of a 9/11 related victim is represented by an attorney for services
rendered in connection with this claim submitted to the U.S. Victims of State Sponsored Terrorism
Fund, the Personal Representative’s attorney must complete the following certification.
I hereby certify that:
The amount I charge for the services I have rendered in connection with this claim,
including fees and costs that if aggregated, did not, does not, and will not exceed 15 percent
of any resulting payment made under the Justice for U.S. Victims of State Sponsored
Terrorism Act, amended by the U.S. Victims of State Sponsored Terrorism Fund
Clarification Act, on this claim.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this _____ day of ________________, 20___
____________________________
Signature of Attorney
Last Name
First Name
Middle Name
Law Firm Name
Mailing Address
City
Email Address
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Facsimile
U.S. Victims of State Sponsored Terrorism Fund
Personal Representative’s Acknowledgment of Attorney’s
Compliance with Statutory Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant (Personal Representative)
Claim Number (if available)
Name of Decedent Victim
If the Personal Representative of a non-9/11 related victim is represented by an attorney for services
rendered in connection with his or her claim submitted to the U.S. Victims of State Sponsored
Terrorism Fund, the Personal Representative must sign and date the following acknowledgment.
I hereby acknowledge that:
Notwithstanding any contract for legal services or retainer agreement, an attorney representing
a Personal Representative Applicant may not charge, receive, or collect, and the Special Master
will not approve, any payment of fees and costs that in the aggregate exceeds 25 percent of any
resulting payment made under the Justice for U.S. Victims of State Sponsored Terrorism Act,
amended by the U.S. Victims of State Sponsored Terrorism Fund Clarification Act, on this
claim. The attorney shall certify his or her compliance with this section. An attorney who
violates this limitation on fees shall be fined under title 18, United States Code, imprisoned for
not more than 1 year, or both.
_____________________________________________________
Signature of Applicant/Personal Representative
_____________________
Date of Signature
(mm/dd/yyyy)
U.S. Victims of State Sponsored Terrorism Fund
Attorney’s Certification of Compliance with Statutory
Limitation on Attorneys’ Fees
OMB No. 1123-0013
Expires 12/31/2022
Name of Applicant (Personal Representative)
Claim Number (if available)
Name of Decedent Victim
If the Personal Representative of a non-9/11 related victim is represented by an attorney for
services rendered in connection with this claim submitted to the U.S. Victims of State Sponsored
Terrorism Fund, the Personal Representative’s attorney must complete the following
certification.
I hereby certify that:
The amount I charge for the services I have rendered in connection with this claim,
including fees and costs that if aggregated, did not, does not, and will not exceed 25 percent
of any resulting payment made under the Justice for U.S. Victims of State Sponsored
Terrorism Act, amended by the U.S. Victims of State Sponsored Terrorism Fund
Clarification Act, on this claim.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this _____ day of ________________, 20___
____________________________
Signature of Attorney
Last Name
First Name
Middle Name
Law Firm Name
Mailing Address
City
Email Address
State
Zip/Postal Code
Telephone
Country (if not in U.S.)
Facsimile
U.S. Victims of State Sponsored Terrorism Fund
Notice of Filing Claim
OMB No. 1123-0013
Expires 12/31/2022
Instructions to the Decedent Victim’s Personal Representative:
You are required to notify all living relatives and potentially interested parties, as listed below, that you are
filing a claim on behalf of the decedent Victim. Follow the instructions below:
1. Complete Part V of the Application Form by following the instructions for that Part. You are
required to list in Part V of the Application Form and deliver a copy of this Notice to the following
people:
The immediate family of the decedent Victim (the spouse, former spouse(s), children, other
dependents, siblings, and parents);
The Executor or Administrator and beneficiaries of the decedent Victim’s will;
The beneficiaries of the decedent Victim’s life insurance policies; and
Any other person who may reasonably be expected to assert an interest in an award or to
have a cause of action to recover damages relating to the wrongful death of the decedent
Victim.
2. Fill out a separate copy of the Notice provided on the next page for each person to whom you are
required to provide a Notice of Filing Claim as listed in Part V of the Application Form. Fill out the
name and address of the person to whom you are providing the Notice and insert the name of the
decedent Victim in the spaces provided below as indicated. You must provide this Notice* to all
living relatives and potentially interested parties, regardless of whether or not they are or will be
included in the Proposed Distribution Plan.
3. Deliver each Notice personally or by certified mail, return receipt requested. Make a copy of the
Notice for your records prior to delivery.
4. Complete the date and method of delivery for each individual in either the appropriate fields in
Part V of the Application Form or in the List of Individuals Notified of Claim Filing form.
__________________________________________________________________________________________
* The Personal Representative must notify everyone specified in Part VII.2 of the U.S Victims of State Sponsored
Terrorism Fund’s Notice published in the Federal Register (Justice for United States Victims of State Sponsored
Terrorism Act, 81 Fed. Reg. 45538 (July 14, 2016)). You do not have to use this particular Notice of Filing
Claim; however, any other notification must meet all of the requirements in Part VII.2 of the Federal Register
Notice.
November 2019
U.S. Victims of State Sponsored Terrorism Fund
Notice of Filing Claim
OMB No. 1123-0013
Expires 12/31/2022
To:
Name:
Address:
You are receiving this Notice to inform you that a claim on behalf of ________________________
(insert name of decedent Victim) is being filed with the U.S. Victims of State Sponsored Terrorism Fund
(“USVSST Fund”). The claim is being filed by _________________ (insert name of Personal Representative).
The rules that govern the USVSST Fund state that only one claim may be filed in connection with the
death of a decedent Victim and that the claim must be filed by the decedent Victim’s Personal Representative.
The rules also state that any payment from the USVSST Fund shall be paid to the Personal Representative and
that the Personal Representative is required to distribute the award among the decedent Victim’s beneficiaries in
accordance with the laws of the decedent Victim’s domicile.
The Personal Representative is informing you that a claim is being filed on behalf of _______________
(insert name of decedent Victim) because the Personal Representative is required to give notice of claim filing
to the decedent Victim’s immediate family; to the Executor, Administrator, and beneficiaries of the decedent
Victim’s will; to the beneficiaries of the decedent Victim’s life insurance policies; and to other people who
might reasonably be expected to assert an interest in an award or to have a cause of action to recover damages
relating to the wrongful death of the decedent Victim.
You are not required to take any action in response to this Notice. However, objections to the authority
of the individual identified as the Personal Representative may be filed with the Special Master by parties who
assert a financial interest in the award up to 30 days following receipt of notice. If timely filed, such objections
will be treated as evidence of a “dispute.” The Special Master shall not be required to arbitrate, litigate, or
otherwise resolve any disputes over the appropriate Personal Representative. Additional information is
available in the USVSST Fund’s Notice published in the Federal Register, 81 Fed. Reg. 45538 (July 14, 2016).
If you want to learn more about the USVSST Fund, please visit the USVSST Fund’s website at
www.usvsst.com or call toll free (855) 720-6966; outside the U.S., please call (614) 553-1013.
Dated: __ /__ /____
mm/dd/yyyy
From the Personal Representative:
Name:
Address:
November 2019
U.S. Victims of State Sponsored Terrorism Fund
List of Individuals Notified of Filing Claim
OMB No. 1123-0013
Expires 12/31/2022
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 12/31/2022
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:
2
U.S. Victims Of State Sponsored Terrorism Fund
List of Individuals Notified of Claim Filing
OMB No. 1123-0013
Expires 12/31/2022
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:
3
U.S. Victims Of State Sponsored Terrorism Fund
List of Individuals Notified of Claim Filing
OMB No. 1123-0013
Expires 12/31/2022
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.
4
U.S. Victims of State Sponsored Terrorism Fund
Proposed Distribution Plan
OMB No. 1123-0013
Expires 12/31/2022
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
Do not know
If “Yes”, has the will been probated? Yes No
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 (“USVSST Fund”) to make a payment, all legal heirs and beneficiaries must consent to participation in
the USVSST 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 12/31/2022
Relationship
to Victim
Name and Address
Social Security/
National Identification/
Telephone Number
% of Award
Other Tax Identification
Number
Spouse
-
-
Former
Spouse
-
-
Registered
Domestic
Partner
-
-
Child
-
-
Child
-
-
Mother
-
-
Father
-
-
Sibling
-
-
Sibling
-
-
Other
(specify)
-
-
Claim Form for Deceased Victim Only
Page 2
U.S. Victims of State Sponsored Terrorism Fund
Proposed Distribution Plan
OMB No. 1123-0013
Expires 12/31/2022
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
U.S. Victims of State Sponsored Terrorism Fund
Consent to Proposed Distribution Plan
OMB No. 1123-0013
Expires 12/31/2022
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)
U.S. Victims of State Sponsored Terrorism Fund
Hearing Request Form
OMB No. 1123-0013
Expires 12/31/2022
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 (“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 denying your claim 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 (mm/dd/yyyy)
_______________________________________
Attorney Signature
________________________
Date (mm/dd/yyyy)
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 USVSST Fund cannot arrange for any
participation other than USVSST Fund officials.
Full Name
Relationship to Claimant and Purpose
of Participation at the Hearing
1
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 12/31/2022
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 Epiq, P.O. Box 10299, Dublin, OH 43017-5899
By overnight courier to U.S. Victims of State Sponsored Terrorism Fund, c/o Epiq, 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.
2
| File Type | application/pdf |
| Author | James Plastiras |
| File Modified | 2019-11-27 |
| File Created | 2019-11-27 |