OMB #1123-0013 USVSST Change of Attorney Form

U.S. Victims of State Sponsored Terrorism Fund Change of Attorney Form OMB No. 1123-0013 Expires [DATE]

Instructions: Use this form if you want to add, change, or remove the attorney representing you before the U.S. Victims of State Sponsored Terrorism Fund (USVSST Fund).

Name of Victim1	Claim Number (if available)
Name of Applicant (if different than Victim)

Please select one of the three options below.

☐ Option 1: I would like to change the attorney representing me before the USVSST Fund. I understand the existing attorney on my claim will be removed and my new attorney will be added.

☐ Option 2: I do not currently have an attorney representing me before the USVSST Fund and would like to add one. I understand that I will no longer represent myself. My new attorney will handle my claim and the Fund will communicate with my attorney.

If you selected Option 1 or 2, please provide the new attorney’s information:

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

Your new attorney must also submit the following documents to the USVSST Fund:

1. ^{Direct Deposit – ACH Payment Form (if not already on file with the} USVSST ^Fund)

2. ^{Applicant’s Acknowledgment of Statutory Limitation on Attorneys’ Fees}

3. ^{Attorney’s Certification of Compliance with Statutory Limitation on Attorneys’ Fees}

☐ Option 3: I would like to remove my attorney from my claim. I wish to represent myself before the USVSST Fund.

You must submit to the USVSST Fund a completed Direct Deposit – ACH Payment Form with the new bank account information to be used for any future payments.

By signing this form, I acknowledge:

1. These changes constitute instructions to the USVSST Fund regarding who can have access to my claim and may change how I will receive payments for my claim.

2. The USVSST Fund cannot provide me any legal advice and will not adjudicate any attorney fee and cost disputes.

3. The USVSST Fund will contact my prior attorneys (if applicable) to notify them that I submitted this Change of Attorney Form.

4. If I added or changed an attorney, 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 USVSST Fund to contact my new attorney or other persons authorized to act on my behalf.

Applicant Signature Date (mm/dd/yyyy)

1 Individuals who are filing a claim on their own behalf are both the Victim and Applicant.

2