OMB #1123-0013 USVSST Application's Acknowledgement of Statutory Limita

U.S. Victims of State Sponsored Terrorism Fund Applicant’s Acknowledgment of Statutory Limitation on Attorneys’ Fees OMB No. 1123‑0013 Expires [DATE]

Instructions: If the Applicant is represented by an attorney before the U.S. Victims of State Sponsored Terrorism Fund, the Applicant must acknowledge the statutory limitation on attorneys’ fees. Applicants who initialed the fee certification in the Application Form do not need to submit this form.

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

I hereby acknowledge that:

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 Justice for United States Victims of State Sponsored Terrorism Act, as amended (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).

Applicant Signature Date (mm/dd/yyyy)

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