OMB #1123-0013 USVSST Hearing Request Form

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

Instructions:

If you are requesting a hearing on the Special Master’s written decision denying your claim in whole or in part, please complete this form and submit it to the U.S. Victims of State Sponsored Terrorism Fund (USVSST Fund). You must request a hearing not later than 30 days after receipt of the Special Master’s written decision. Once you submit your completed form and any additional documentation and the USVSST Fund grants your request for a hearing, the USVSST Fund will contact you with details about your hearing.

If you are represented by an attorney, please consult with your attorney before submitting this form. It is important that only one form be submitted to the USVSST Fund to ensure appropriate action on your claim.

Name of Applicant

Claim Number

I request a hearing regarding the Special Master’s denial of my claim in whole or in part.

Applicant Signature Date (mm/dd/yyyy)

^{Attorney Signature (if applicable) D}ate (mm/dd/yyyy)

Pre-Hearing Questionnaire

1. Indicate which portion(s) of your claim you believe was/were not properly decided. Please be as detailed as possible to enable the USVSST Fund to fully prepare for your hearing. If you have additional documentation you have not submitted to the USVSST Fund that you want provide for your hearing, you should submit a copy of the documentation with this form.

2. Who, if anyone, will be participating at the hearing on your behalf? It is your responsibility to request and arrange this participation and to notify the participants of the hearing. The USVSST Fund may establish procedures for attendance and participation in hearings, but the USVSST Fund cannot arrange for any participation other than USVSST Fund officials.

Full Name	Relationship to Applicant and Purpose of Participation at the Hearing

3. Do you have any special needs or requirements specific to your hearing?

If you have any questions regarding this Hearing Request Form, please email the USVSST Fund or call the toll‑free helpline at (855) 720‑6966. If you are calling from outside the U.S., please call +1 (614) 553‑1013.

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