OMB #1123-0013 USVSST Fund Application Form

U.S. Victims of State Sponsored Terrorism Fund Application Form OMB No. 1123‑0013 Expires [DATE]

Instructions:

Please completely answer the questions in this Application Form (Application Form) to submit a claim for compensation from the U.S. Victims of State Sponsored Terrorism Fund (Fund). To submit a claim to the Fund, you must submit an Application Form and required documents electronically by visiting www.usvsst.com. Only one Application Form may be submitted for each claim and only the Personal Representative(s) may submit a claim for a deceased Victim.

When completing this Application Form, you must:

• Submit your answers in English.

• Provide individuals’ full legal names.

• Upload required documentation with your Application Form.

• Electronically initial and sign the Signatures and Certifications pages of your completed Application Form.

• Submit your application via the Fund’s online claims portal.

Filing Deadline:

A claim based on a final judgment obtained on or after July 14, 2016 must be submitted no later than 90 days after the date of obtaining the final judgment, unless otherwise specified in the Justice for United States Victims of State Sponsored Terrorism Act, as amended.

Required Documentation Checklist:

The Application Form includes a document checklist to assist you in gathering and submitting the document(s) needed to process your claim.

Submitting Your Application Form Online:

All Fund applications are filed via the online claims portal. You must complete your Application Form and upload documentation using the Fund’s online portal available on the Fund’s website, www.usvsst.com.

It is very important to inform the Fund of any changes in mailing addresses, telephone numbers, or email addresses because the Fund will use that information to contact you or your attorney about your claim. You, or if you are represented, your attorney, should log into your online account and change your contact information, as applicable. Please note that if you are represented by an attorney, the Fund will contact your attorney regarding your claim.

If you need assistance with this online Application Form, or have any questions, please email [email protected] or call our toll‑free helpline at (855) 720‑6966. If you are calling from outside the United States, please call collect at +1 (614) 553‑1013.

Privacy Act Notice:

By submitting this Application Form, you are authorizing the U.S. Department of Justice to collect this information as allowed by the Justice for United States Victims of State Sponsored Terrorism Act (Act), codified at 34 U.S.C. § 20144 (formerly 42 U.S.C. § 10609). The information you submit in your claim, including but not limited to your Social Security Number, is for official use by the U.S. Department of Justice for the purposes of determining your eligibility for, and the amount of, compensation you may receive under your claim to the Fund. In addition, Executive Order 9397 (November 22, 1943) authorizes federal agencies to use Social Security numbers as individual identifiers to distinguish between people with the same or similar names, and 5 U.S.C. § 5514, 26 U.S.C. §§ 6402, 6331, 31 U.S.C. §§ 3711‑20E, 42 U.S.C. § 664, and other applicable legal authorities, authorize the Department of the Treasury and other officials disbursing federal payments to use individual Social Security numbers to identify federal payment recipients who owe a delinquent debt. Providing this information is voluntary; however, failure to provide complete information may result in a delay in processing or a denial of your claim. Information you submit regarding your claim may be disclosed by the U.S. Department of Justice only in accordance with the provisions of the Privacy Act, including the routine uses indicated below:

1. To the Department of Treasury to ensure that any recipients of federal payments who also owe delinquent federal debts have their payment offset or withheld or reduced to satisfy the debt.

2. 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.

3. In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the Department of Justice 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.

4. To an actual or potential party to litigation or the party’s authorized representative for the purpose of negotiation or discussion of such matters as settlement, plea bargaining, or in informal discovery proceedings.

5. To the news media and the public, including disclosures pursuant to 28 C.F.R. § 50.2, unless it is determined that release of the specific information in the context of a particular case would constitute an unwarranted invasion of personal privacy.

6. 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.

7. To a former employee of the Department for purposes of: responding to an official inquiry by a federal, state, or local government entity or professional licensing authority, in accordance with applicable Department regulations; or facilitating communications with a former employee that may be necessary for personnel ‑related or other official purposes where the Department requires information and/or consultation assistance from the former employee regarding a matter within that person’s former area of responsibility.

8. 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.

9. To appropriate agencies, entities, and persons when (1) the Department suspects or has confirmed that there has been a breach of the system of records; (2) the Department has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, DOJ (including its information systems, programs and operations), the Federal Government, or national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with the Department’s efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm.

10. To the National Archives and Records Administration for purposes of records management inspections conducted under the authority of 44 U.S.C. §§ 2904 and 2906.

11. To another Federal agency or Federal entity, when the Department determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.

12. To professional organizations or associations with which individuals covered by this system of records may be affiliated, such as state bar disciplinary authorities, to meet their responsibilities in connection with the administration and maintenance of standards of conduct and discipline.

13. To any agency, organization, or individual for the purpose of performing authorized audit or oversight operations of the Department and meeting related reporting requirements.

14. To such recipients and under such circumstances and procedures as are mandated by Federal statute or treaty.

Paperwork Reduction Act Notice:

This request is in accordance with the Paperwork Reduction Act of 1995. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it contains a currently valid Office of Management and Budget (OMB) approval number. We try to create forms and instructions that are accurate, can be easily understood, and that impose the least possible burden on you. The information collected in this Application Form is for the purpose of determining your eligibility for, and the amount of, compensation you may receive based on your claim to the Fund. The average estimated time for applicants to complete the Application Form is 1.25 hours.

Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of the Special Master, U.S. Victims of State Sponsored Terrorism Fund, U.S. Department of Justice, 950 Pennsylvania Ave, NW, Washington, DC 20530; OMB control number 1123‑0013.

Information About the Victim

The term “Victim” refers to a U.S. person who has secured a final judgment in a U.S. district court under state or federal law against a state sponsor of terrorism and arising from an act of international terrorism, for which the foreign state was found not immune under section 1605A, or section 1605(a)(7), of title 28, United States Code (Foreign Sovereign Immunities Act, “FSIA”).

Please complete the information below. Please use the individual’s full legal name.

Please Note: If you are a Personal Representative who is filing on behalf of a deceased Victim, please complete the information below to the extent possible for the deceased Victim.

Last Name		First Name			Middle Name
Mailing Address
City		State		Zip/Postal Code		Country (if not U.S.)
Telephone Number		Email Address
Date of Birth (mm/dd/yyyy)		Social Security Number or Taxpayer Identification Number (if any)
Is or was the Victim a U.S. citizen? ☐ Yes ☐ No If No, provide:
National Identification Number	Country of Citizenship		Passport Number				Passport Country
Does the Victim or has the Victim ever used any other names (e.g., maiden name or nickname)? ☐ Yes ☐ No If Yes, provide:
Last Name		First Name			Middle Name

Information About the Applicant

The term “Applicant” refers to the individual who is filing the Fund claim to seek compensation for the Victim. Individuals who are filing a claim on their own behalf are both the Applicant and the Victim.

In what capacity are you filing the claim? Select one from the list below:

☐ Self – I am the Victim.

For Applicants who are not the Victim:

☐ Personal Representative for the deceased Victim.

☐ Parent or guardian of a minor Victim. Please provide additional information below:

 I have sole legal custody of the minor.

 I share or have joint legal custody of the minor.

☐ Guardian of a non-minor Victim.

☐ Other (please specify):

For Attorneys:

If your client is the Victim, please select “Self” above.

If your client is an Applicant other than the Victim (such as a Personal Representative), please select the Applicant’s capacity above.

Complete the following information for the Applicant:

Last Name		First Name			Middle Name
Mailing Address
City		State		Zip/Postal Code		Country (if not U.S.)
Telephone Number		Email Address
Date of Birth (mm/dd/yyyy)		Social Security Number or Taxpayer Identification Number (if any)
Is or was the Applicant a U.S. citizen? ☐ Yes ☐ No If No, provide:
National Identification Number	Country of Citizenship		Passport Number				Passport Country
Does the Applicant or has the Applicant ever used any other names (e.g., maiden name or nickname)? ☐ Yes ☐ No If Yes, provide:
Last Name		First Name			Middle Name

If applicable, complete the following information for the co‑Applicant (e.g., the co‑Personal Representative or the person with whom you share custody or guardianship of the Victim).

Please Note: All Applicants’ signatures are required wherever the Fund asks for a signature.

☐ Not Applicable

Last Name		First Name			Middle Name
Mailing Address
City		State		Zip/Postal Code		Country (if not U.S.)
Telephone Number		Email Address
Date of Birth (mm/dd/yyyy)		Social Security Number or Taxpayer Identification Number (if any)
Is or was the Applicant a U.S. citizen? ☐ Yes ☐ No If No, provide:
National Identification Number	Country of Citizenship		Passport Number				Passport Country
Does the Applicant or has the Applicant ever used any other names (e.g., maiden name or nickname)? ☐ Yes ☐ No If Yes, provide:
Last Name		First Name			Middle Name

Information About the Applicant’s Attorney (If Applicable)

If an attorney is representing the Applicant for this claim, complete the information below:

Please Note: The Fund will communicate with the attorney you identify. You must provide documentation of your attorney’s authority to represent you, and you and your attorney must complete the certification acknowledging statutory limitations on attorneys’ fees and costs.

Name of Attorney
Law Firm Name
Mailing Address
City	State	Zip/Postal Code	Country (if not U.S.)
Email Address		Telephone Number

Eligibility for Compensation

In order for the Victim to receive compensation from the Fund, the Victim must hold a final judgment issued by a U.S. district court under state or federal law, awarding the Victim compensatory damages on a claim(s) brought by the Victim arising from acts of international terrorism for which the foreign state was found not immune from the jurisdiction of the courts of the United States under the FSIA (FSIA final judgment). The Applicant must complete this Part and provide the appropriate supporting documents. A document checklist is available at the end of the Application Form.

Please provide the information below:

Case Name	U.S. District Court
Case Number Docket / Electronic Case Filing (ECF) Number of the Final Judgment	Compensatory Damages Award Amount
State Sponsor(s) of Terrorism	Name of the individual(s) whose personal injury or death was the basis for the FSIA final judgment (FSIA Victim)
Is the Victim’s claim related to the acts of international terrorism carried out on September 11, 2001?		☐ Yes ☐ No

Identify the immediate family members of the FSIA Victim. Immediate family members are spouses, domestic partners, children, stepchildren, parents, stepparents, brothers, sisters, half‑brothers, and half‑sisters of those individual(s).

Please Note: The Victim’s immediate family members may be different than the immediate family members of the FSIA Victim.

Did any immediate family member(s) of the FSIA Victim(s) obtain any separate final judgment(s) based on the same act of international terrorism? ☐ Yes ☐ No

If Yes, complete the information below. Do not include any immediate family members listed in the same judgment as the Victim.

Last Name	First Name	Middle Name
Last Name	First Name	Middle Name

Other Information in Support of Application

Compensation From Sources Other Than This Fund

All Applicants must complete this section. Please identify compensation from any source other than this Fund that the Victim, or the Victim’s beneficiaries, received or is entitled to receive as a result of the act of international terrorism that gave rise to the Victim’s final judgment. Sources other than this Fund include life insurance; pension funds; death benefit programs; payments by federal, state, or local governments; and court-awarded compensation related to the act that gave rise to the judgment.

Indicate below whether the Victim or the Victim’s beneficiaries received or is entitled to receive:

Program/Benefits	Y/N	Amount	Source(s)
Life insurance, pension funds, or death benefit programs	☐ Yes ☐ No
Payments by federal, state, or local governments	☐ Yes ☐ No
Court‑awarded compensation related to the act which gave rise to the judgment	☐ Yes ☐ No
Any other source(s) of compensation not already listed (If any, please provide the type and source in the “Source(s)” column)	☐ Yes ☐ No

IMPORTANT NOTE: Applicants or their attorneys MUST inform the Fund of any compensation that the Victim, or the Victim’s beneficiaries, received or is entitled to receive from sources other than this Fund throughout the life of the Fund.

Additional Information (Optional)

Use this area to provide any other information that may be relevant to the individual circumstances of this claim. Please also identify here and submit any additional documents not already requested that may be relevant.

Additional Information for Claim Filed for Deceased Victim (If Applicable)

Is the Applicant filing a claim on behalf of a deceased Victim? ☐ Yes ☐ No

I have the authority to file this claim on behalf of the deceased Victim because:

☐ I am the court‑appointed Personal Representative, executor, or administrator of the deceased Victim’s will or estate.

You must provide a copy of the court appointment document.

☐ I am named as the executor or administrator in the deceased Victim’s will.

You must provide a copy of the testamentary document.

☐ I am the first person in the line of succession established by the laws of the deceased Victim’s domicile governing intestacy.

You must identify and submit an explanation of any applicable laws to support your authority to file a claim on behalf of the deceased Victim. If any other individuals share priority with you in the line of succession, those individuals must consent to your serving as Personal Representative.

Please provide the Victim’s date of death:

IMPORTANT NOTE: When filing a claim on behalf of the deceased Victim, Personal Representatives must certify that they have provided written notice of the claim to:

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

• The executor or administrator and the beneficiaries of the deceased Victim’s will; and

• 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 are required to provide notice to everyone in the categories above, even if they are not included in the deceased Victim’s will, in accordance with Part VII of the Fund’s July 14, 2016 Notice published in the Federal Register and also available on the Fund’s website at www.usvsst.com. A sample Notice of Filing Claim is available on the Fund’ s website. Personal Representatives are not required to submit copies of the written notices or proof of delivery to the Fund.

Signatures and Certifications

By submitting this Application Form, you are agreeing that you understand the notices below, including the Privacy Act Notice (as referenced fully in the instructions), authorization to communicate with your attorney or other representative, and the statutory limitation on attorneys’ fees.

Instructions: Checking the boxes below means you read and understand each certification. If an Applicant is represented by an attorney for their USVSST Fund claim, the Applicant’s attorney may electronically initial and sign this Application Form on the Applicant’s behalf.

For all Applicants, please initial to acknowledge that:
_________ Applicant Initials	I certify, under oath, subject to penalty of perjury or in a manner that meets the requirements of 28 U.S.C. § 1746, that the information provided in the Application Form and any documents submitted in support of the claim are true and accurate to the best of my knowledge, and I agree that any payment made by the Fund is expressly conditioned upon the truthfulness and accuracy of the information and documentation submitted in support of the claim. When a Victim is represented by a third party, such as a Victim’s legal guardian, the Personal Representative of the deceased Victim’s estate, or other person legally authorized to act for the Victim, these persons must have authority to certify on behalf of the Victim.
_________ Applicant Initials	I understand that false statements or claims made in connection with the claim may result in fines, imprisonment, and/or any other remedy available by law to the federal government, including as provided in 18 U.S.C. § 1001, and that claims that appear to be potentially fraudulent or to contain false information will be forwarded to federal, state, and local law enforcement authorities for possible investigation and prosecution.
_________ Applicant Initials	I authorize the U.S. Department of Justice to disclose any records or information relating to my claim in accordance with the Privacy Act Notice, including the routine uses it identifies. This includes the disclosure of any records or information relating to my claim for the purpose of determining qualification and/or compensation of my claim specifically to: agency contractors performing or working on a contract, service, grant, cooperative agreement, or other assignment for the federal government when necessary for administration of the Fund; and the Department of the Treasury to ensure that any recipients of federal payments who also owe delinquent debts have their payment offset or withheld or reduced to satisfy the debt.
_________ Applicant Initials	If I receive payment under the Justice for United States Victims of State Sponsored Terrorism Act, as amended (Act), I agree and accept that the United States shall be subrogated to the rights of the Victim (and any of the Victim’s heirs, successors, or assignees) to the extent and in the amount of such payment, but that, to the extent amounts of damages remain unpaid and outstanding to the Victim following any payments made under this Act, each Victim shall retain creditor rights in any unpaid or outstanding amounts of the judgment, including any prejudgment or post‑judgment interest, or punitive damages, awarded by a U.S. district court pursuant to a judgment.

For Applicants who are represented by an attorney, you and your attorney must initial to acknowledge that:
_________ Applicant Initials _________ Attorney Initials	No attorney representing a non‑9/11‑related victim of state sponsored terrorism shall charge, receive, or collect, and the Special Master shall not approve, any payment of fees and costs that in the aggregate exceeds 25 percent of any payment made under the Act. No attorney representing a 9/11‑related victim of state sponsored terrorism shall charge, receive, or collect, and the Special Master shall not approve, any payment of fees and costs that in the aggregate exceeds 15 percent of any payment made under the Act. The attorney shall certify compliance with this statutory limitation and shall provide such information as the Special Master requires ensuring such compliance. An attorney who violates this limitation on fees shall be fined under title 18, United States Code, imprisoned for not more than one (1) year, or both. See 34 U.S.C. § 20144(f).
For Applicants with an attorney or other authorized representative or alternative contact, please initial to acknowledge that:
_________ Applicant Initials	I authorize the Special Master, the Special Master’s designees, the U.S. Department of Justice, or agency contractors assisting in the administration of the Fund to contact my attorney or other persons authorized to act on my behalf.
For Applicants filing on behalf of a deceased Victim, please initial to acknowledge that:
_________ Applicant Initials	I certify that I have provided the required Notice of Filing Claim to all of the decedent’s living relatives and potentially interested parties by personal delivery; certified mail, return receipt requested; or other delivery method the Special Master deems appropriate, and that I am not aware of anyone else to whom such notice should be provided.

Applicant Signature Date (mm/dd/yyyy)

Applicant Name

Document Checklist

You must provide the applicable documentation described below to establish eligibility for payment under the Act. In certain cases, the Special Master may request additional documentation. Providing thorough documentation is the best way to ensure your Application Form is processed quickly. All documents you submit to establish eligibility will be reviewed and considered by the Special Master.

If you submit any documents in a language other than English, you must also provide a complete translation into English. In addition, you must include a certification from the translator in English that the translation is complete and accurate and that the translator is competent. The certification must include the date and the translator’s name, signature, and address.

You must submit any requests for waiver of a documentation requirement or an extension of time in which to submit a particular document to the Special Master in writing at least 20 business days prior to the application deadline. Decisions to waive a documentation requirement or to extend the time to submit a particular document are wholly within the discretion of the Special Master.

You must submit all supporting documentation with your Application Form. Applicants do not need to submit multiple copies of the same document. One document may satisfy several of the requirements below.

Document Requirements for all Applicants

A copy of the final judgment. Please Note: You should include all court documents demonstrating that the judgment is a qualifying final judgment (e.g., action brought under the FSIA, award for compensatory damages, and the individual award amount).	☐
Proof of service of the final judgment.	☐

Additional Document Requirements for Applicants Who Are Not the Victim (select one)

Personal Representative of deceased Victim: Copies of legal documentation showing sufficient evidence of authority to represent the estate of the deceased Victim, such as court orders, letters testamentary or similar documentation. Please Note: In the case of claims brought by a foreign citizen on behalf of a deceased Victim, the Special Master may alter the document requirements.	☐
Representative of minor Victim: A copy of a court order or other document issued by an official showing appointment as the guardian or other authorized representative of the minor Victim.	☐
Representative of non-minor Victim: A copy of a court order or other document issued by an official showing appointment as the guardian or other authorized representative of the Victim.	☐

Additional Document Requirements for Applicants Represented by an Attorney

Documentation of the attorney’s authority to represent the Applicant, such as a copy of the retainer agreement or contract for legal services.

☐

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