OMB #1123-0013 USVSST Authorization for Communication

U.S. Victims of State Sponsored Terrorism Fund Authorization For Communication OMB No. 1123-0013 Expires [DATE]

Notice: As a general matter, if an Applicant is represented by an attorney before the U.S. Victims of State Sponsored Terrorism Fund (USVSST Fund), the USVSST Fund can communicate only with the Applicant’s attorney. Except for notices of a change of attorney,¹ if represented Applicants or their alternative contacts communicate separately with the USVSST Fund, the USVSST Fund directs its response and the incoming communication to the Applicant’s attorney. The USVSST Fund will send claim records only to Applicants or their attorneys.

Instructions: If an Applicant wants to authorize the USVSST Fund to communicate with an individual regarding the claim, please complete this form with the new alternative contact’s name and contact information, the Applicant’s signature, and the date, and return the form to the USVSST Fund. Applicants should not submit this form for authorized representatives, alternative contacts, or attorneys previously listed in the Application Form.

Name of Victim2	Claim Number
Name of Applicant (if different than Victim)

Alternative Contact:

Last Name		First Name			Middle Name
Mailing Address
City	State			Zip/Postal Code		Country (if not U.S.)
Email Address
Telephone Number			Relationship to Applicant

I authorize the Special Master, the Special Master’s designees, the U.S. Department of Justice, and agency contractors assisting in the administration of the USVSST Fund to communicate with this Alternative Contact regarding my claim.

Applicant Signature Date (mm/dd/yyyy)

1 See Change of Attorney Form, available on the USVSST Fund website at www.usvsst.com.

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