Statement Claim Form

OMB Approval Number: 1105-0100
Expiration Date: 11/30/2016

U.S. DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION

(FOR FCSC USE ONLY)
CLAIM NO.

STATEMENT OF CLAIM
FOR FILING OF CLAIMS INCLUDED WITHIN A CATEGORY OF CLAIMS REFERRED TO THE
COMMISSION BY THE DEPARTMENT OF STATE PURSUANT TO SECTION 4(a)(1)(C) OF THE
INTERNATIONAL CLAIMS SETTLEMENT ACT OF 1949, AS AMENDED, 22 U.S.C. § 1623(a)(1)(C).
Please select the date of the letter of referral from the Department of State (Referral Letter) under which the
present claim is filed.
Please select the country against which the present claim is filed.

CONTACT INFORMATION

1. CLAIMANT
Name of Claimant
(Last)

(Middle)

(First)

Name of Company/Firm
(Street Address)
(State/Territory)

(City)

(Zip Code)

Home Phone

Work Phone
Email
Name of Injured Party if different from that of claimant
Relation to Injured Party
2. LEGAL REPRESENTATIVE (if any)
Name of Legal Representative
(Last)

(Middle)

(First)

Name of Law Firm
(Street Address)
(City)
Phone

(State/Territory)

(Zip Code)

Fax

Email
Paperwork Reduction Act Statement: This information collection has been cleared under the Paperwork Reduction Act of 1995, 44 U.S.C. 3501 et seq. (Control No. 1105-0100).
Under 44 U.S.C. 3506(c)(1)(B)(iii)(V), an agency may not conduct or sponsor, and a person may not be required to respond to, an information collection request unless the
information collection form bears a valid control number. Completion of this form is mandatory in order to obtain compensation. The estimated burden associated with this
collection of information is 2.0 hours per respondent or recordkeeper.

FORM FCSC-1

BASIC CLAIM INFORMATION
3. U.S. NATIONALITY
3.1 Nationality of Individual Claimants
Please state how and when you acquired U.S. nationality and provide supporting documentation:
By birth in the United States - provide the date and place of birth

By naturalization in the United States - provide the date and place of naturalization

Other - provide the date on which, and the manner by which, U.S. nationality was acquired (for example, by birth abroad to U.S.
parents, derivative naturalization, etc.)

3.2 Nationality of Corporate Claimants
3.2.1 Please indicate below the date and State of incorporation.

3.2.2 How many shares of capital stock of all classes or other beneficial interest did the entity
have outstanding on the date of loss?
3.2.3 How many shares of capital stock of all classes or other beneficial interest were owned by
U.S. nationals on the date of loss?
3.2.4 How many shares of capital stock of all classes or other beneficial interest did the entity
have outstanding on the effective date of the pertinent claims settlement agreement?
3.2.5 How many shares of capital stock of all classes or other beneficial interest were owned by
U.S. nationals on the effective date of the pertinent claims settlement agreement?
3.2.6 Please attach the Articles of Incorporation and a statement by the Secretary or other principal officer of the corporation (or other entity)
certifying all of the above.

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4. CLAIM DETAILS

Please select the specific Category of Claim(s), from among those described in the Referral Letter, under which the present claim is
filed.

Please describe the merits of your claim and attach all supporting documentation. (Attach additional sheets as necessary) The elements
required to prove the claim are described in the instructions for the particular program.

5. RELEASE AND PENALTIES (Each claimant must sign individually. Please make additional copies of this page as necessary.)

RELEASE: The information provided in this Statement of Claim and in any attachments, and any material and information
submitted before or after this Statement of Claim in regard to or in support of the claim, will be treated as public information. The
aforementioned information and materials may be made available to interested persons who make inquiries about the claims program, in
conformity with the Freedom of Information Act. Any decision issued by the Commission in relation to this Statement of Claim will be
made publicly available, including via the Internet. By your signature on this Statement of Claim, you acknowledge that you are aware
of and agree to the making of such disclosures, and that you authorize the Foreign Claims Settlement Commission and its staff to conduct
any investigation needed to decide your claim.
PENALTIES: Your attention is directed to the federal law on false statements, 18 U.S.C. section 1001, which provides:
[W]hoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United
States, knowingly and willfully–
(1) falsifies, conceals or covers up by any trick, scheme, or device a material fact;
(2) makes any false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially,
fictitious, or fraudulent statement or entry;
shall be fined under [Title 18, U.S. Code] or imprisoned not more than 5 years, or both.
I,

certify that I have read the release and agree to
(Name of Claimant or Duly Authorized Officer)

its terms. I further certify that, to the best of my knowledge and belief, the statements set forth in this Statement of Claim, including any
papers attached to or filed with this Statement of Claim, are true and accurate, and that all material facts have been set forth in this Statement
of Claim.
Date

Signature of Claimant or Duly Authorized Officer

Date

Legal Representative Signature

6. FEES LIMITATION (Must be signed by claimant's Legal Representative (if any).)
LEGAL FEES: Your attention is directed to 22 U.S.C. § 1623(f), which states: "No remuneration on account of services rendered on behalf
of any claimant in connection with any claim filed with the Commission under this title shall exceed 10 per centum of the total amount paid
pursuant to any award certified under the provisions of this title, on account of such claim. Any agreement to the contrary shall be unlawful
and void."
I,

certify that I have read 22 U.S.C.§ 1623(f), and that I agree to, and I am bound by, its terms.
(Name of Legal Representative)

Date

Legal Representative Signature

Privacy Act Statement
The Foreign Claims Settlement Commission (the Commission) is authorized to collect the information requested on this form (or requested at any other time
regarding this claim) under 22 U.S.C. 1621 et seq. The information collected will be used to enable the Commission to carry out its statutory responsibility to
determine the validity and amount of the claims submitted to it under 22 U.S.C. 1623(a)(1)(C). Furnishing the requested information to the Commission is
voluntary; however, failure to provide such information may result in either the delay of the adjudication or denial of the claim. Information collected may be
disclosed pursuant to routine uses, published at 78 Fed. Reg. 39012 (6/28/2013). Such routine uses include:
·
To the Department of State and the Department of the Treasury in connection with the negotiation, adjudication, settlement and payment of claims;
·
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;
·
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;
·
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;
·
In an appropriate proceeding before the Commission, or before a court, grand jury, or administrative or adjudicative body, when the Department of
Justice and/or the Foreign Claims Settlement Commission 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.