Benefits Package and Supporting Documentation

Countermeasures Injury Compensation Program (CICP)

OMB: 0915-0334

IC ID: 208418

Documents and Forms

Document Name Document Type
Compensation Attachment 1.docx Instruction
Compensation Attachment 1 for Reps.docx Instruction
Compensation Attachment 1 for Estate.docx Instruction
4.1 Certification of Status for Death Benefit – Alternate Calculation Certification of Status for Death Benefit - Alternative Calculation.docx Form
4.2 Certification of Status for Death Benefit - Standard Calculation Certification of Status for Death Benefit - Standard Calculation.docx Form
4.3 Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient Death Benefit Certification of Relationship Survivor.docx Form
4.4 Certification of Status for Administrators of the Estate: Lost Employment Income Lost Employment Income Certification - Estate.docx Form
4.5 Certification of Status: Lost Employment Income Lost Employment Income Certification.docx Form
4.6 Certification of Status: Unreimbursed Medical Expenses Unreimbursed Medical Expenses Certification.docx Form
10162023 - (08) Recipient Requester Package - Compensation Letter - CLEAN.docx Instruction
10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses... - CLEAN.docx Instruction
10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses... - REDLINE.docx Instruction
Attachment 2 Unreimbursed Medical Expenses Certification A (Clean) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - CLEAN.docx Form and Instruction
Attachment 2 Unreimbursed Medical Expenses Certification (Redline) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - REDLINE.docx Form and Instruction
Attachment 3 Lost Employment Income Certification A (Clean) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - CLEAN.docx Form and Instruction
Attachment 3 Lost Income Certification A (Redline) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - REDLINE.docx Form and Instruction
10162023 - (12) Estate Package - Compensation Letter - CLEAN.docx Instruction
10162023 - (12) Estate Package - Compensation Letter - REDLINE.docx Instruction
10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - CLEAN.docx Instruction
10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - REDLINE.docx Instruction
10162023 - (14) Survivor Package - Compensation Letter - CLEAN.docx Instruction
10162023 - (14) Survivor Package - Compensation Letter - REDLINE.docx Instruction
Attachment 2 - Estate Unreimbrused Medical Expenses Certification (Clean) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - CLEAN.docx Form and Instruction
Attachment 2 - Estate Unreimbursed Medical Expenses Certification (redline) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - REDLINE.docx Form and Instruction
Attachment 3 - Estate Lost Income Certification 10162023 - (16) Estate Package - Attachment 3 - Lost Employment Income Certification - CLEAN.docx Form and Instruction
Attachment 1 - Survivor Certifcation of Status for Death Benefit (clean) 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - CLEAN.docx Form and Instruction
Attachment 1 - Survivor Certification of Status for Death Benefit - Redline 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - REDLINE.docx Form and Instruction
Attachment 2 - Survivor Certification of Status for Death Benefit - Alternative Calculation (Clean) 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - CLEAN.docx Form and Instruction
Attachment 2 - Survivor Certification of Status for Death Benefit - Alternative Calculation (redline) 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - REDLINE.docx Form and Instruction
Attachment 3 - Survivor Survivor Attachment 3 - Death Benefit Certification of Relationship Redline 10112023 - (19) Survivor Package - Attachment 3 - Death Benefit Certification of Relationship - REDLINE.docx Form and Instruction