OMB #1123-0013 UVSST Attorney's Fee Certification

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

Instructions: Attorneys who represent Applicants before the U.S. Victims of State Sponsored Terrorism Fund must certify their compliance with the statutory limitation on attorneys’ fees. Attorneys 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)

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

I hereby certify my compliance with the following:

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. I shall provide such information as the Special Master requires ensuring my compliance. An attorney who violates this limitation 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).

Attorney Signature Date (mm/dd/yyyy)

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