OMB #1123-0013 USVSST Certification of Personal Representative

U.S. Victims of State Sponsored Terrorism Fund Certification of Personal Representative OMB No. 1123‑0013 Expires [DATE]

Name of Applicant (Personal Representative)	Claim Number (if available)
Name of Deceased Victim

I submit this certification in connection with the claim I filed with the U.S. Victims of State Sponsored Terrorism Fund (USVSST Fund) on behalf of the estate of the deceased Victim.

I understand that I have a continuing obligation to update claim information, including information concerning my authority to represent the estate of the deceased Victim.

I am still the authorized Personal Representative of the estate of the deceased Victim.

My status as Personal Representative is not the subject of pending litigation or other dispute.

I will distribute the USVSST Fund award in a manner consistent with the deceased Victim’s will, the law of the deceased Victim’s domicile, or a ruling by a court of competent jurisdiction; or in accordance with the terms of an agreement among all beneficiaries who would be entitled to a share of the award.

Applicant (Personal Representative) Signature Date (mm/dd/yyyy)