OMB #1123-0013 USVSST informer Information and Acknowledgement

U.S. Victims of State Sponsored Terrorism Fund Informer Information and Acknowledgment OMB No. 1123‑0013 Expires [DATE]

Notice: This form should only be used if you are seeking compensation as an informer.

Under the Justice for United States Victims of State Sponsored Terrorism Act (Act), as amended, informers who meet the statutory requirements may receive an award of 10 percent of the related funds deposited in the U.S. Victims of State Sponsored Terrorism Fund. See 34 U.S.C. § 20144(g); see also Justice for United States Victims of State Sponsored Terrorism Act, 81 Fed. Reg. 45,535, 45,539 (July 14, 2016).

Requirements:

1. The individual must hold a final judgment described in subsection (c)(2)(A) or a claim under subsection (c)(2)(B) or (c)(2)(C) of the Act;

2. The individual must have identified and notified the Attorney General of funds or property of a state sponsor of terrorism, or held by a third party on behalf of or subject to the control of that state sponsor of terrorism; that were not previously identified or known by the United States Government; and that are subsequently forfeited directly or in the form of substitute assets to the United States; and

3. The Attorney General must find that the individual’s notification and identification of funds or property substantially contributed to the forfeiture to the United States.

Acknowledgement:

I acknowledge that I must meet all of the requirements in 34 U.S.C. § 20144(g) in order to receive compensation as an informer. On (date), I notified the Attorney General in writing by contacting the Chief, Money Laundering, Narcotics and Forfeiture Section (formerly, Money Laundering and Asset Recovery Section), Criminal Division, Department of Justice, 950 Pennsylvania Avenue N.W., Washington, DC 20530-0001, of funds or property of a state sponsor of terrorism, or held by a third party on behalf of or subject to the control of that state sponsor of terrorism. A copy of that communication is attached.

Signature Date (mm/dd/yyyy)

Printed Name Claim Number (if applicable)