Notice of Filing C USVSST Notice of Claim

U.S. Victims of State Sponsored Terrorism Fund Notice of Filing Claim OMB No. 1123‑0013 Expires 01/31/2026

Instructions to the deceased 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 deceased Victim.

1. The immediate family of the deceased Victim (the spouse, former spouse(s), children, other dependents, siblings, and parents);

2. The Executor or Administrator and beneficiaries of the deceased Victim’s will; and

3. 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.

You should 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 above. Enter the name of the recipient, the Personal Representative (you), and the deceased Victim in the spaces provided. You must provide this Notice to all living relatives and potentially interested parties, regardless of whether or not they are or will be receiving a distribution.

You must deliver each Notice personally or by certified mail, return receipt requested. You should make a copy of each Notice for your records prior to delivery. You are not required to submit copies of the Notices or proof of delivery to the Fund.

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* 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. 45,538 (July 14, 2016)). You do not have to use this particular Notice of Filing Claim form; however, any other notification must meet all of the requirements in Part VII.2 of the Federal Register Notice.

To (Recipient)	Date of Notice
From (Personal Representative)	Name of Deceased Victim

Notice

The Personal Representative is filing a claim with the U.S. Victims of State Sponsored Terrorism Fund (USVSST Fund) on behalf of the deceased Victim. The Personal Representative is sending you this Notice to inform you about the claim. You are not required to take any action in response to this Notice.

Additional Information

Only one claim may be filed in connection with the death of a deceased Victim. The deceased Victim’s Personal Representative must file that claim. The USVSST Fund must direct any payment to the Personal Representative.

The Personal Representative is informing you that a claim is being filed on behalf of the deceased Victim because the Personal Representative is required to give notice of claim filing to the deceased Victim’s immediate family; to the Executor, Administrator, and beneficiaries of the deceased Victim’s will; 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 deceased Victim.

You are not required to take any action in response to this Notice. However, up to 30 days following receipt of notice, parties who assert a financial interest in the award may file with the Special Master an objection to the authority of the individual identified to file the claim as the Personal Representative. If timely filed, an objection will be treated as evidence of a “dispute.” The Special Master shall not be required to arbitrate, litigate, or otherwise resolve any disputes as to the identity of the Personal Representative. Additional information is available in the USVSST Fund’s Notice published in the Federal Register, 81 Fed. Reg. 45,538 (July 14, 2016).

Please visit the USVSST Fund’s website at www.usvsst.com for additional information. If you have any questions, please feel free to email the USVSST Fund at [email protected] or call the USVSST Fund’s toll‑free helpline at (855) 720‑6966. If you are calling from outside the United States, please call +1 (614) 553‑1013.