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International Terrorism Victim Expense Reimbursement Program
ICR 202606-1121-003 · OMB 1121-0309 · Object 170107300.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | International Terrorism Victim Expense Reimbursement Program |
| Author | VM |
| Last Modified By | Writer |
| File Modified | 2017-12-28 |
| File Created | 2026-06-19 |
| Conversion State | complete |
Extracted Text
Supplemental Sheet F: MEDICAL EXPENSES If necessary, please attach additional sheets using this format. Medical Expense Please list each medical expense for which you are seeking reimbursement Describe the Medical Expense What Was the Out of Pocket Cost? Date Medical Expense Was Incurred Name of Service Provider Contact Person’s Name: E-mail Telephone: Provider’s Address City State Zip Code Medical Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses. Coverage Source’s Name Policy # - Acct # - Claim # Contact Person’s Name: Coverage Source’s Address Source’s Telephone Source’s E-mail/Fax Medical Expense Please list each medical expense for which you are seeking reimbursement Describe the Medical Expense What Was the Out of Pocket Cost? Date Medical Expense Was Incurred Name of Service Provider Contact Person’s Name: E-mail Telephone: Provider’s Address City State Zip Code Medical Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses. Coverage Source’s Name Policy # - Acct # - Claim # Contact Person’s Name: Coverage Source’s Address Source’s Telephone Source’s E-mail/Fax Please attach supporting documentation for each expense such as insurance statements, invoices, copies of receipts, credit card statements, Explanation of Benefits, etc. Supplemental Sheet G: MENTAL HEALTH EXPENSES If necessary, please attach additional sheets using this format. Mental Health Expense Please list each mental health expense for which you are seeking reimbursement Describe the Medical Expense What Was the Out of Pocket Cost? Date Medical Expense Was Incurred Name of Service Provider Contact Person’s Name: E-mail Telephone: Provider’s Address City State Zip Code Mental Health Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses. Coverage Source’s Name Policy # - Acct # - Claim # Contact Person’s Name: Coverage Source’s Address Source’s Telephone Source’s E-mail/Fax Mental Health Expense Please list each mental health expense for which you are seeking reimbursement Describe the Medical Expense What Was the Out of Pocket Cost? Date Medical Expense Was Incurred Name of Service Provider Contact Person’s Name: E-mail Telephone: Provider’s Address City State Zip Code Mental Health Coverage Please identify all sources of financial assistance for each expense, including family members or friends who may have covered your expenses. Coverage Source’s Name Policy # - Acct # - Claim # Contact Person’s Name: Coverage Source’s Address Source’s Telephone Source’s E-mail/Fax Please attach supporting documentation for each expense such as insurance statements, invoices, copies of receipts, credit card statements, Explanation of Benefits, etc. Supplemental Sheet H: PROPERTY LOSS EXPENSES If necessary, please attach additional sheets using this format. Please list in detail, your specific items below. Item Name Detailed Description Cost at time of purchase Was the item insured? Attached Supporting Documentation Example: Digital Camera 1 Canon PowerShot S95 Camera with 10 megapixels, 4x zoom, 3” LCD display and SD memory card slot. $865.00 no Receipt Please attach supporting documentation for each expense such as copies of receipts, credit card statements, pictures of the items, etc. Supplemental Sheet I: FUNERAL & BURIAL EXPENSES If necessary, please attach additional sheets using this format. Please list in detail, your requested expenses below: Type of Expense Detailed Description Total Cost at time of purchase Amount covered by other sources Purpose of Expense Attached Supporting Documentation For each expense you must attach copies of supporting documentation. Third Party Contributions: Has any other person(s) such as a family member or friend, paid for part of the out-of-pocket funeral and/or burial expenses for which you are seeking reimbursement? If so, complete the chart below. Person Who Paid Contact Information for Person(s) Who Paid Relationship Between Claimant and Who Paid Amount Paid For What Expense Name Address, e-mail and telephone Name Address, e-mail and telephone Name Address, e-mail and telephone Please attach supporting documentation for each expense such as copies of receipts, credit card statements, etc. Supplemental Sheet J: MISCELLANEOUS EXPENSES If necessary, please attach additional sheets using this format. Please list your specific expenses below. Type of Expense Detailed Description Cost at time expense was incurred Amount covered by other sources Purpose of Expense Attached Supporting Documentation Example: Phone bill Phone charges from India to Knoxville, TN while in India attending to victim’s affairs – June/July 2004 $384.28USD no Putting victim’s affairs in order Phone bill For each expense you must attach copies of supporting documentation. Third Party Contributions: Has any other person(s) such as a family member or friend, paid for part of the out-of-pocket funeral and/or burial expenses for which you are seeking reimbursement? If so, complete the chart below. Person Who Paid Contact Information for Person(s) Who Paid Relationship Between Claimant and Who Paid Amount Paid For What Expense Name Address, e-mail and telephone Name Address, e-mail and telephone