United States Victims of State Sponsored Terrorism Fund Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OMB #1123-0013 USVSST Certification of Personal Representative	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST Direct Deposit Form	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST informer Information and Acknowledgement	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST Hearing Request Form	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST Authorization for Communication	Form and Instruction	Modified	Available
Form OMB #1123-0013 UVSST Attorney's Fee Certification	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST Application's Acknowledgement of Statutory Limitation on Attorneys' Fees	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST Change of Attorney Form	Form and Instruction	Modified	Available
Form OMB #1123-0013 USVSST Fund Application Form	Form and Instruction	Modified	Available
Form Notice of Filing C USVSST Notice of Claim	Form and Instruction	Modified	Available
Form Notice of Filing C USVSST Application	Form and Instruction	Modified	Repair queued
Nonmaterial Change Justification 1123-0013.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-04-17	Available
Nonmaterial Change Justification 1123-0013.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-04-17	Missing upstream
Memo 1123-0013.docx	Supplementary Document	Uploaded 2019-11-29	Available
Memo 1123-0013.docx	Supplementary Document	Uploaded 2019-11-29	Repair queued
Published 30-Day Notice.pdf	Supplementary Document	Uploaded 2019-10-16	Available
Published 30-Day Notice.pdf	Supplementary Document	Uploaded 2019-10-16	Repair queued
VSST ACH Form 9.20.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
VSST ACH Form 9.20.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
PR's Acknowledgment of Attorney's Compliance with Limitation on Attorney.pdf	Supplementary Document	Uploaded 2016-10-20	Available
PR's Acknowledgment of Attorney's Compliance with Limitation on Attorney.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Notice of Filing Claim 10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Notice of Filing Claim 10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Hearing Request Form.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Hearing Request Form.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Draft List of Individuals (for Notice of Filing Claim) 10.6.16 1115am.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Draft List of Individuals (for Notice of Filing Claim) 10.6.16 1115am.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Draft Distribution Plan 10.07.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Draft Distribution Plan 10.07.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Consent to Distribution_10.5.16 v2.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Consent to Distribution_10.5.16 v2.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Authorization for Communication Correspondence PR_10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Authorization for Communication Correspondence PR_10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Authorization for Communication Correspondence nonPR 10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Authorization for Communication Correspondence nonPR 10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Attorney Change or Removal Form.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Attorney Change or Removal Form.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Attorney Certification for Fee Limitation_PR.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Attorney Certification for Fee Limitation_PR.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Attorney Certification for Fee Limitation nonPR 10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Available
Attorney Certification for Fee Limitation nonPR 10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Applicant's Acknowledgment of Attorney's Compliance with Limitation on A.10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
Applicant's Acknowledgment of Attorney's Compliance with Limitation on A.10.5.16.pdf	Supplementary Document	Uploaded 2016-10-20	Repair queued
1140-0010 supporting statement part A 2025.clean.kk.docx	Supporting Statement A	Uploaded 2026-01-23	Available
1140-0010 supporting statement part A 2025.clean.kk.docx	Supporting Statement A	Uploaded 2026-01-23	Repair queued
42 USC 10609.pdf	Supplementary Document	Uploaded 2016-07-08	Available
42 USC 10609.pdf	Supplementary Document	Uploaded 2016-07-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
222379	USVSST Application	Form and Instruction	Modified	USVSST Certification of Personal Representative
222379	USVSST Application	Form and Instruction	Modified	USVSST Direct Deposit Form
222379	USVSST Application	Form and Instruction	Modified	USVSST informer Information and Acknowledgement
222379	USVSST Application	Form and Instruction	Modified	USVSST Hearing Request Form
222379	USVSST Application	Form and Instruction	Modified	USVSST Authorization for Communication
222379	USVSST Application	Form and Instruction	Modified	UVSST Attorney's Fee Certification
222379	USVSST Application	Form and Instruction	Modified	USVSST Application's Acknowledgement of Statutory Limitation on Attorneys' Fees
222379	USVSST Application	Form and Instruction	Modified	USVSST Change of Attorney Form
222379	USVSST Application	Form and Instruction	Modified	USVSST Fund Application Form
222379	USVSST Application	Form and Instruction	Modified	USVSST Notice of Claim
222379	USVSST Application	Form and Instruction	Modified

ICR Details

OMB Control No: 1123-0013	ICR Reference No: 202601-1123-001
Status: Historical Inactive	Previous ICR Reference No: 202304-1123-001
Agency/Subagency: DOJ/CD	Agency Tracking No: 1123-0013
Title: United States Victims of State Sponsored Terrorism Fund Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 03/12/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/23/2026
Terms of Clearance: Wrong supporting statement included. Please resubmit with correct documents.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2026	36 Months From Approved	03/31/2026
Responses	700	0	700
Time Burden (Hours)	875	0	875
Cost Burden (Dollars)	0	0	0

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Abstract: The United States Victims of State Sponsored Terrorism Fund (Fund) provides compensation to certain individuals who were injured as a result of an international act of terrorism by a state sponsor of terrorism. The Justice for United Victims of State Sponsored Terrorism Act sets forth criteria for eligibility under the Fund, such as a final judgment issued against a state sponsor of terrorism. The Fund Application Form requests information to determine eligibility and amount of compensation.

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Authorizing Statute(s): US Code: 42 USC 10609 Name of Law: Justice for United States Victims of State Sponsored Terrorism Act
  

Citations for New Statutory Requirements: US Code: 42 USC 10609(b)(2)(B) Name of Law: Justice for United States Victims of State Sponsored Terrorism Act
US Code: 42 USC 10609(c)(3)(A) Name of Law: Justice for United States Victims of State Sponsored Terrorism Act
US Code: 42 USC 10609(d)(2) Name of Law: Justice for United States Victims of State Sponsored Terrorism Act
US Code: 42 USC 10609(b)(4)(A) Name of Law: Justice for United States Victims of State Sponsored Terrorism Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 53390	11/25/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 2967	01/23/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
USVSST Application	Notice of Filing Claim, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013, OMB #1123-0013	USVSST Notice of Claim ,   USVSST Fund Application Form ,   USVSST Change of Attorney Form ,   USVSST Application's Acknowledgement of Statutory Limitation on Attorneys' Fees ,   UVSST Attorney's Fee Certification ,   USVSST Authorization for Communication ,   USVSST Hearing Request Form ,   USVSST informer Information and Acknowledgement ,   USVSST Direct Deposit Form ,   USVSST Certification of Personal Representative

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/23/2026

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