United States Victims of State Sponsored Terrorism Fund Application

Forms and Documents

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

IC Document Collections

IC ID	Document Title	Status
222379	USVSST Application Form and Instruction	Modified

ICR Details

OMB Control No: 1123-0013	ICR Reference No: 202601-1123-001
Status: Received in OIRA	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	Date Submitted to OIRA: 01/23/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2026
Responses	700	700
Time Burden (Hours)	875	875
Cost Burden (Dollars)	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

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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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	700	700	0	0	0	0
Annual Time Burden (Hours)	875	875	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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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