W000613
Monday, November 26, 2001 3:02 PM
-----Original Message-----
Fedreg notice of Nov 5 2001--proposed rules
In response to the Federal Register notice of November 5, 2001, the Foreign Claims Settlement Commission offers the following comments and suggestions:
Re topics 1 and 2: Forms to be used and information to be included thereon.
For your convenience, attached are the electronic versions of the draft claim forms we provided to last month.
Based on our experience, and the practice of the Civil Division with its radiation claims, we recommend that the regulations provide only for filing of claims via paper claim forms physically delivered to the Department via mail, in person, or via express delivery service (though the forms should be available to download and print, as Civil does). This will lessen confusion that could result in attempting to match electronic or faxed forms with paper evidence sent separately. The regulations should also include language strongly encouraging claimants to include the evidence needed to support their claims along with their completed claim forms.
As for when a claim should be deemed "filed," we believe that should be when the filled-out claim form has been physically received by Department. We would further recommend that the Department print an acknowledgment postcard to be mailed to each claimant to confirm receipt. We believe this would best insure consistency and even treatment of all claimants in the application of the 120-day processing requirement in the statute.
Re topic 3: Procedures for hearing and presentation of evidence.
The regulations should include a statement that an employee of the Department will review the claim form and supporting evidence as promptly as possible following receipt and will notify the claimant of any missing information or documentation or any clarification that needs to be submitted. The regulations should further specify, however, that the employee will have authority to grant the claimant a period of not more than 45 days within which to provide the missing information or documentation, or the requested clarification, and that because of the 120-day processing requirement in the statute, the claimant will run the risk of having his or her claim denied if the claimant does not provide those materials within the 45-day period.
Rather than saying the claim would be "dismissed" as "not properly filed," we recommend that the regulations be modeled on those of the FCSC (45 CFR 531--to be changed to 509 in the next edition) which provide for "denial" of a claim that is lacking one or more elements of compensability, with the further provision that the claimant can "object" to the denial and request reconsideration based on the submission of additional evidence and information. However, the regulations should also put a short deadline such as 30 days within which the claimant would be allowed to "object" or appeal from the denial.
As for the form that hearings on appeals would take, we believe that given the anticipated large numbers of claims and short time within which to complete their processing, hearings should be limited to paper hearings--or as our regulations call them, "hearings on the record."
On the subject of "hearing officers," we recommend based on our experience that the hearings on the record be carried out by staff attorneys who would make recommendations to the Special Master on disposition of the objections/appeals. We do not believe that claimants should have access to internal, interim "working decisions" on their claims.
Re topic 4: Procedures for filing and pursuing claims.
The only comment we can offer is that under the International Claims Settlement Act (ICSA), attorneys' fees are limited to 10 percent of the amounts actually paid to claimants before the FCSC, and it is a misdemeanor for attorneys to demand any greater amount. However, neither the FCSC nor the Treasury Department is involved in the payment of the fees; on the contrary, award payment checks must by statute be drawn directly in the name of the claimant in each case. In the case of the P.L. 107-42 program, we would assume that fees could not be limited unless there were an amendment to the law to that effect.
We have no experience regarding payments of fees to experts and how they are negotiated and paid by claimants, as those are matters we consider to be between the claimants and their experts.
The ICSA also limits representation before the FCSC to attorneys licensed to practice in a State or Territory of the U.S., or the District of Columbia. However, the FCSC generally has sought to be flexible in allowing claimants who are deficient in English or of infirm health to be assisted by relatives or friends.
Re topic 5: Claimant eligibility.
We have no specific comments to offer, other than to observe that the criteria and procedures devised to determine eligibility should be designed to identify the intended beneficiaries of the legislation as quickly and accurately as possible.
Re topic 6: Nature and amount of compensation.
We have no specialized expertise in this area, and thus have no specific comments to offer. On the question of fraud prevention measures, though, we would note that the FCSC has always included on its claim forms a note directing claimants' attention to the criminal law on the making of false statements to the U.S. Government, 18 U.S.C. 1001.
Comment by:
Foreign Claims Settlement Commission
Attachment 1:
(1)
PRELIMINARY DRAFT FORM A
U.S. DEPARTMENT OF JUSTICE
OMB Approval No.
Approval Expires:
{ (FOR OFFICE USE ONLY) }
{ }
STATEMENT OF CLAIM
{ CLAIM NO. }
{ }
{ }
FOR FILING OF CLAIMS UNDER TITLE IV OF THE AIR TRANSPORTATION SAFETY AND SYSTEM
STABILIZATION ACT OF 2001 (PUBLIC LAW 107-42, APPROVED SEPTEMBER 22, 2001)
FORM A.: FOR USE BY PERSONS WHO SUFFERED PHYSICAL HARM WHILE PRESENT AT THE WORLD
TRADE CENTER (NEW YORK, NEW YORK) THE PENTAGON (ARLINGTON, VIRGINIA), OR THE SITE OF
THE AIRCRAFT CRASH AT SHANKSVILLE, PENNSYLVANIA, OR IN THE IMMEDIATE AFTERMATH, OF
THE TERRORIST-RELATED AIRCRAFT CRASHES OF SEPTEMBER 11, 2001
FORM B.: FOR USE BY THE PERSONAL REPRESENTATIVE OF INDIVIDUALS WHO WERE KILLED OR WHO
DIED IN THE IMMEDIATE AFTERMATH OF THE TERRORIST-RELATED AIRCRAFT CRASHES OF SEPTEMBER
11, 2001, EXCEPT THOSE INDIVIDUALS IDENTIFIED BY THE ATTORNEY GENERAL TO HAVE BEEN A
PARTICIPANT OR A CONSPIRATOR IN THE CRASHES.
UPON THE SUBMISSION OF THIS CLAIM, THE CLAIMANT WAIVES THE RIGHT TO FILE A CIVIL
ACTION (OR TO BE A PARTY TO AN ACTION) IN FEDERAL OR STATE COURT FOR DAMAGES
SUSTAINED AS A RESULT OF THE TERRORIST RELATED AIRCRAFT CRASHES OR SEPTEMBER 11, 2001.
NOTE: To assist in deciding your claim quickly and fairly, please fill out this STATEMENT OF CLAIM form CAREFULLY
AND COMPLETELY. Please TYPE or PRINT clearly. BEFORE you start this form, PLEASE READ the Instructions that
come with it. You may attach additional pages to this form if you need more space for your answers.
Please note that only ONE claim may be submitted by an individual or on behalf of a deceased individual.
Paperwork Reduction Act Statement: This information collection has been cleared under the Paperwork Reduction Act of 1995. The estimated burden
associated with this collection of information is 2.0 hours per respondent or recordkeeper. Comments concerning the accuracy of this burden estimate and
(2)
suggestions for reducing this burden should be directed to the Foreign Claims Settlement Commission, Department of Justice, Washington, DC 20579,
and the Office of Management and Budget, Paperwork Reduction Project (1105-----), Washington, DC 20503
PLEASE FILL OUT THIS FORM AND SEND IT TO THE DEPARTMENT OF JUSTICE NO LATER THAN
DECEMBER , 2003. KEEP A COPY FOR YOUR FILES.
THIS CLAIM INVOLVES THE TERRORIST ATTACK AT THE:
WORLD TRADE CENTER ( ) THE PENTAGON ( ) SHANKSVILLE, PA ( )
1. NAME OF
CLAIMANT:(MR./MS.)
(LAST) (FIRST) (MIDDLE)
2. MAILING
ADDRESS:
WORK PHONE: ( )
FAX: ( )
EMAIL ADDRESS:
3. GIVE THE NAME, MAILING ADDRESS AND PHONE NUMBER OF THE LAWYER (IF ANY)
REPRESENTING YOU IN THIS CLAIM.
PHONE: ( )
FAX: ( )
EMAIL ADDRESS: ( )
4. GIVE THE NAME, MAILING ADDRESS AND PHONE NUMBER OF SOMEONE AT A DIFFERENT ADDRESS
WHOM WE CAN CONTACT IF WE CANNOT LOCATE YOU:
PHONE: ( )
FAX:( )
EMAIL ADDRESS:( )
IMPORTANT: YOU MUST TELL THE DEPARTMENT IF YOU MOVE. IF YOUR ADDRESS
CHANGES AND YOU DO NOT TELL THE DEPARTMENT, YOU MAY UNNECESSARILY
DELAY YOUR CLAIM.
(3)
5. STATE YOUR DATE AND PLACE OF BIRTH:
SOCIAL SECURITY NUMBER:
CITIZENSHIP: PASSPORT #/COUNTRY OF ISSUE:
__________________________________________________________________________________________
GREEN CARD:
WORK PERMIT:
PLEASE ATTACH COPIES OF PASSPORT/GREEN CARD/WORK PERMIT
6. STATE YOUR OCCUPATION (JOB TITLE) AS OF SEPTEMBER 11, 2001:__________________________
_________________________________________________________________________________________________
NAME OF EMPLOYER/PLACE OF EMPLOYMENT AS OF SEPTEMBER 11, 2001/ADDRESS/NAME OF
EMPLOYER/CONTACT PERSON/TELEPHONE NUMBER (IF HOME OR FAMILY CARE GIVER, BRIEFLY
DESCRIBE RESPONSIBILITIES):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
TYPE OF EMPLOYMENT/LENGTH OF EMPLOYMENT: (IF RETIRED AND/OR PENSION FROM ONE OR
MORE JOBS, GIVE NAME AND ADDRESS OF THE COMPANIES)
_________________________________________________________________________________________________
FULL-TIME ( ) CIVILIAN ( ) SOCIAL SECURITY RECIPIENT ( )
PART-TIME ( ) GOVERNMENT ( ) OTHER ( )
CONTRACTOR ( ) INTERMITTENT ( )
PLEASE STATE YOUR YEARLY SALARY INCLUDING BONUSES AND OTHER REMUNERATIONS:
_________________________________________________________________________________________________
(4)
7. IF CURRENT EMPLOYMENT IS DIFFERENT THAN THAT YOU HAVE LISTED ABOVE, PLEASE STATE
NAME OF CURRENT EMPLOYER AND YOUR CURRENT JOB TITLE:
8. PLEASE EXPLAIN IN DETAIL THE NATURE AND EXTENT OF THE PHYSICAL HARM YOU SUSTAINED
ON SEPTEMBER 11, 2001. PROVIDE THE SPECIFIC LOCATION WHERE THE INJURY WAS SUSTAINED.
9. STATE THE NAME, ADDRESS AND DATE OF TREATMENT OF EACH PERSON WHO PROVIDED YOU
WITH MEDICAL TREATMENT OR SERVICES RELATED TO YOUR INJURY.
10. DESCRIBE ANY PROJECTED LONG TERM DISABILITIES IF KNOWN, AND PROVIDE THE NAME AND
ADDRESS OF ANY TREATING PHYSICIAN WHO PROVIDED YOU WITH THIS DIAGNOSIS.
(5)
PLEASE INCLUDE DOCUMENTATION TO SUPPORT THE ABOVE PORTION OF YOUR CLAIM
SUMMARY OF LOSSES CLAIMED
11. DESCRIPTION AND VALUE OF YOUR DAMAGES:
ECONOMIC LOSSES AS A RESULT OF YOUR INJURY:
LOSS OF INCOME/EARNINGS:
MEDICAL EXPENSES:
REPLACEMENT SERVICES LOSS:
LOSS OF BUSINESS OR EMPLOYMENT OPPORTUNITIES (Please note that claims for such loss shall be
considered to the extent recovery for such loss is allowed under applicable State law):
OTHER:
12. NON-ECONOMIC LOSSES SUCH AS: PHYSICAL AND EMOTIONAL PAIN, SUFFERING,
INCONVENIENCE, PHYSICAL IMPAIRMENT, MENTAL ANGUISH, DISFIGUREMENT, LOSS OF
ENJOYMENT OF LIFE, LOSS OF SOCIETY AND COMPANIONSHIP, LOSS OF CONSORTIUM (OTHER
THAN LOSS OF DOMESTIC SERVICE), HEDONIC DAMAGES, INJURY TO REPUTATION, AND ALL
OTHER NON-PECUNIARY LOSSES OF ANY KIND OR NATURE.
13. PROVIDE ANY OTHER INFORMATION OR DOCUMENTATION WHICH MAY HELP THE
DEPARTMENT DECIDE THIS CLAIM.
(6)
14. PLEASE STATE THE TOTAL DOLLAR AMOUNT OF YOUR CLAIM(S):___________________________
15. COMPENSATION: PLEASE INDICATE IF YOU HAVE RECEIVED ANY COMPENSATION FROM ANY
COLLATERAL SOURCE, INCLUDING EMERGENCY RELIEF PAYMENTS, UNEMPLOYMENT
COMPENSATION, MEDICAL OR OTHER PERSONAL INSURANCE COVERAGE, PENSION FUNDS,
PAYMENTS BY FEDERAL, STATE OR LOCAL GOVERNMENTS OR ANY CHARITABLE
ORGANIZATION RELATED TO THE SEPTEMBER 11, 2001 INCIDENT.
SOURCES AND AMOUNTS RECEIVED:____________________________________________________________
DATE(S) RECEIVED:______________________________________________________________________________
PLEASE ATTACH ANY DOCUMENTS WHICH MAY VERIFY SUCH PAYMENTS.
16. IF YOU CURRENTLY HAVE A CLAIM FOR COLLATERAL COMPENSATION PENDING, IDENTIFY THE
ENTITY AGAINST WHOM YOU HAVE MADE THE CLAIM.
UPON THE SUBMISSION OF THIS CLAIM, THE CLAIMANT WAIVES THE RIGHT TO FILE A CIVIL
ACTION (OR TO BE A PARTY TO AN ACTION) IN FEDERAL OR STATE COURT FOR DAMAGES
SUSTAINED AS A RESULT OF THE TERRORIST RELATED AIRCRAFT CRASHES OR SEPTEMBER 11, 2001.
17. RELEASE: THE INFORMATION PROVIDED IN THIS STATEMENT OF CLAIM AND ANY
ATTACHMENTS, AND ANY MATERIAL INFORMATION SUBMITTED BEFORE OR AFTER THIS
STATEMENT OF CLAIM IN REGARD TO OR IN SUPPORT OF THE CLAIM, WILL BE USED ONLY BY THE
DEPARTMENT TO DECIDE YOUR CLAIM. BY YOUR SIGNATURE ON THIS STATEMENT OF CLAIM,
YOU ACKNOWLEDGE THAT YOU ARE AWARE OF AND AGREE TO THIS DISCLOSURE POLICY, AND
YOU AUTHORIZE THE DEPARTMENT AND ITS STAFF TO CONDUCT ANY INVESTIGATION AND/OR
AUDIT NEEDED TO DECIDE YOUR CLAIM.
18. CERTIFICATION
I, , CERTIFY THAT
(Type or print your name)
I AM AUTHORIZED TO MAKE THIS CERTIFICATION ON BEHALF OF THE CLAIMANT.
(STATE YOUR RELATIONSHIP TO CLAIMANT):_______________________________________________
(7)
I FURTHER CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE STATEMENTS SET
FORTH IN THIS STATEMENT OF CLAIM, INCLUDING ANY PAPERS ATTACHED TO OR FILED WITH THE
STATEMENT OF CLAIM, ARE TRUE AND ACCURATE, AND THAT ALL MATERIAL FACTS HAVE BEEN
SET FORTH IN THIS STATEMENT OF CLAIM.
DATE SIGNATURE
COUNTY OF _________________________________
STATE OF ____________________________________
Sworn and subscribed to before me this day of , 200
NOTARY PUBLIC
PENALTIES
YOUR ATTENTION IS DIRECTED TO THE FEDERAL LAW ON FALSE STATEMENTS, 18 U.S.C. SECTION 1001,
WHICH PROVIDES:
"WHOEVER, IN ANY MATTER WITHIN THE JURISDICTION OF ANY DEPARTMENT OR AGENCY OF THE
UNITED STATES, KNOWINGLY AND WILLFULLY FALSIFIES, CONCEALS OR COVERS UP BY ANY
TRICK, SCHEME, OR DEVICE A MATERIAL FACT, OR MAKES ANY FALSE, FICTITIOUS OR
FRAUDULENT STATEMENTS OR REPRESENTATIONS, OR MAKES OR USES ANY FALSE WRITING OR
DOCUMENT KNOWING THE SAME TO CONTAIN ANY FALSE, FICTITIOUS OR FRAUDULENT
STATEMENT OR ENTRY, SHALL BE FINED NOT MORE THAN $10, 000 OR IMPRISONED NOT MORE
THAN FIVE YEARS, OR BOTH."
MAIL THIS FORM TO:
911 VICTIM COMPENSATION
U.S. DEPARTMENT OF JUSTICE
WASHINGTON, DC 20530
BE SURE TO ATTACH DOCUMENTS TO HELP PROVE YOUR CLAIM.
NOTE: EACH DOCUMENT IN A FOREIGN LANGUAGE MUST BE ACCOMPANIED BY A VERIFIED ENGLISH
TRANSLATION.
(8)
IF YOU HAVE ANY QUESTIONS REGARDING THE COMPLETION OF THIS FORM, PLEASE CALL:
Attachment 2:
(1)
PRELIMINARY DRAFT FORM B
U.S. DEPARTMENT OF JUSTICE
OMB Approval No. _
Approval Expires:
{ (FOR OFFICE USE ONLY) }
{ }
STATEMENT OF CLAIM
{ CLAIM NO. }
{ }
{ }
FOR FILING OF CLAIMS UNDER TITLE IV OF THE AIR TRANSPORTATION SAFETY AND SYSTEM
STABILIZATION ACT OF 2001 (PUBLIC LAW 107-42, APPROVED SEPTEMBER 22, 2001)
FORM A.: FOR USE BY PERSONS WHO SUFFERED PHYSICAL HARM WHILE PRESENT AT THE WORLD TRADE
CENTER (NEW YORK, NEW YORK) THE PENTAGON (ARLINGTON, VIRGINIA), OR THE SITE OF THE
AIRCRAFT CRASH AT SHANKSVILLE, PENNSYLVANIA, OR IN THE IMMEDIATE AFTERMATH, OF THE
TERRORIST-RELATED AIRCRAFT CRASHES OF SEPTEMBER 11, 2001
FORM B.: FOR USE BY THE PERSONAL REPRESENTATIVE OF INDIVIDUALS WHO WERE KILLED OR
WHO DIED IN THE IMMEDIATE AFTERMATH OF THE TERRORIST-RELATED AIRCRAFT CRASHES OF
SEPTEMBER 11, 2001, EXCEPT THOSE INDIVIDUALS IDENTIFIED BY THE ATTORNEY GENERAL TO
HAVE BEEN A PARTICIPANT OR A CONSPIRATOR IN THE CRASHES.
UPON SUBMISSION OF THIS CLAIM, THE CLAIMANT WAIVES THE RIGHT TO FILE A CIVIL ACTION (OR
TO BE A PARTY TO AN ACTION) IN ANY FEDERAL OR STATE COURT FOR DAMAGES SUSTAINED AS
A RESULT OF THE TERRORIST RELATED AIRCRAFT CRASHES OF SEPTEMBER 11, 2001.
NOTE: To assist in deciding your claim quickly and fairly, please fill out this STATEMENT OF CLAIM form CAREFULLY
AND COMPLETELY. Please TYPE or PRINT clearly. BEFORE you start this form, PLEASE READ the Instructions that
come with it. You may attach additional pages to this form if you need more space for your answers.
Please note that only ONE claim may be submitted by an individual or on behalf of a deceased individual.
If you have any questions regarding completion of this form, please contact .
Paperwork Reduction Act Statement: This information collection has been cleared under the Paperwork Reduction Act of 1995. The estimated burden
associated with this collection of information is 2.0 hours per respondent or recordkeeper. Comments concerning the accuracy of this burden estimate and
(2)
suggestions for reducing this burden should be directed to the Foreign Claims Settlement Commission, Department of Justice, Washington, DC 20579,
and the Office of Management and Budget, Paperwork Reduction Project (1105-----), Washington, DC 20503.
PLEASE FILL OUT THIS FORM AND SEND IT TO THE DEPARTMENT OF JUSTICE NO LATER THAN
DECEMBER , 2003. KEEP A COPY FOR YOUR FILES.
THIS CLAIM INVOLVES THE TERRORIST ATTACK AT THE:
WORLD TRADE CENTER ( ) THE PENTAGON ( ) SHANKSVILLE, PA ( )
1. NAME OF THE DECEASED**:
(LAST) (FIRST) (MIDDLE)
LAST KNOWN ADDRESS OF DECEASED:
DECEDENT'S DATE AND PLACE OF BIRTH:
DECEDENT'S SOCIAL SECURITY NUMBER:
CITIZENSHIP: PASSPORT NUMBER/COUNTRY OF ISSUE:
GREEN CARD:
WORK PERMIT:
**IF THERE IS MORE THAN ONE DECEDENT IN A FAMILY, PLEASE PROVIDE IDENTICAL
INFORMATION ON A SEPARATE SHEET.
PLEASE ATTACH COPIES OF PASSPORT/GREEN CARD/WORK PERMIT
2. NAME OF PERSONAL REPRESENTATIVE OF THE DECEDENT:
(MR./MS.)
(LAST) (FIRST) (MIDDLE)
MAILING
ADDRESS:
WORK PHONE: ( )
HOME PHONE: ( )
FAX: ( )
EMAIL ADDRESS:
(3)
3. GIVE THE NAME, MAILING ADDRESS AND PHONE NUMBER OF THE LAWYER (IF ANY)
REPRESENTING YOU IN THIS CLAIM.
PHONE: ( )
FAX: ( )
EMAIL ADDRESS:
4. GIVE THE NAME, MAILING ADDRESS AND PHONE NUMBER OF SOMEONE AT A DIFFERENT ADDRESS
WHOM WE CAN CONTACT IF WE CANNOT LOCATE YOU:
PHONE: ( )
FAX: ( )
EMAIL ADDRESS:
IMPORTANT: YOU MUST TELL THE DEPARTMENT IF YOU MOVE. IF YOUR ADDRESS
CHANGES AND YOU DO NOT TELL THE DEPARTMENT, YOU MAY UNNECESSARILY
DELAY YOUR CLAIM.
5. STATE DECEDENT'S OCCUPATION (JOB TITLE) AS OF SEPTEMBER 11, 2001:
NAME OF DECEDENT'S EMPLOYER/PLACE OF EMPLOYMENT/ADDRESS/EMPLOYER CONTACT
PERSON: (If decedent was a home or family care giver, briefly describe responsibilities)
6a. TYPE OF EMPLOYMENT/LENGTH OF EMPLOYMENT: (If retired and/or pensioned from one or more jobs, give
name and addresses of the companies)
(4)
6b. FULL-TIME ( ) CIVILIAN ( ) S.S. RECIPIENT ( )
PART-TIME ( ) GOVERNMENT ( ) OTHER ( )
CONTRACTOR ( ) INTERMITTENT ( )
6c. PLEASE STATE DECEDENT'S YEARLY SALARY, INCLUDING BONUSES AND OTHER
REMUNERATIONS
_________________________________________________________________________________________________
PLEASE INCLUDE DOCUMENTATION TO SUPPORT THE ABOVE PORTION OF YOUR CLAIM
7. PLEASE EXPLAIN TO THE BEST OF YOUR ABILITY, THE CIRCUMSTANCES LEADING TO THE DEATH
OF THE DECEDENT, INCLUDING THE DECEDENT'S PHYSICAL LOCATION AT THE TIME OF THE
INCIDENT, AND THE CAUSE AND TIME OF DEATH, IF KNOWN.
IMPORTANT: PLEASE ATTACH A CERTIFIED COPY OF THE DEATH CERTIFICATE OR EXPLAIN WHY
NONE IS AVAILABLE. ALSO, PLEASE ENCLOSE A CERTIFIED COPY OF DECEDENT'S LAST WILL AND
TESTAMENT, PROBATE DECREE, AND ANY OTHER PERTINENT DOCUMENTATION IN SUPPORT OF
YOUR CLAIM.
8. PLEASE PROVIDE NAMES, RELATIONSHIPS TO THE DECEDENT, AND ADDRESSES OF ANY OTHER
INDIVIDUALS WHO MAY HAVE AN INTEREST IN THIS CLAIM.
SUMMARY OF LOSSES CLAIMED
9. DESCRIPTION AND VALUE OF DECEDENT'S DAMAGES:
ECONOMIC LOSSES OF THE DECEDENT:
BURIAL AND RELATED COSTS:
LOSS OF INCOME/EARNINGS:
MEDICAL EXPENSES (IF APPLICABLE):
REPLACEMENT SERVICES LOSS:
(5)
LOSS OF BUSINESS OR EMPLOYMENT OPPORTUNITIES (to the extent recovery for such loss is allowed
under applicable State law):____________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
OTHER:
10. NON-ECONOMIC LOSSES OF THE DECEDENT SUCH AS: PHYSICAL AND EMOTIONAL PAIN,
SUFFERING, INCONVENIENCE, PHYSICAL IMPAIRMENT, MENTAL ANGUISH, DISFIGUREMENT,
LOSS OF ENJOYMENT OF LIFE, LOSS OF SOCIETY AND COMPANIONSHIP, LOSS OF CONSORTIUM
(OTHER THAN LOSS OF DOMESTIC SERVICE), HEDONIC DAMAGES, INJURY TO REPUTATION, AND
ALL OTHER NON-PECUNIARY LOSSES OF ANY KIND OR NATURE.
11. PROVIDE ANY OTHER INFORMATION OR DOCUMENTATION WHICH MAY HELP THE
DEPARTMENT DECIDE THIS CLAIM.
12. PLEASE STATE THE TOTAL DOLLAR AMOUNT OF YOUR CLAIM(S):
(6)
13. COMPENSATION: PLEASE INDICATE IF DECEDENT'S ESTATE HAS RECEIVED ANY
COMPENSATION FROM ANY COLLATERAL SOURCE, SUCH AS LIFE INSURANCE, PENSION FUNDS,
DEATH BENEFIT PROGRAMS, AND PAYMENTS BY FEDERAL, STATE OR LOCAL GOVERNMENTS
OR ANY CHARITABLE ORGANIZATION RELATED TO THE SEPTEMBER 11, 2001 INCIDENT.
SOURCE(S) AND AMOUNT(S) RECEIVED:
DATE(S) RECEIVED:
PLEASE ATTACH ANY DOCUMENTS WHICH MAY VERIFY SUCH PAYMENTS
14. IF THERE IS CURRENTLY A CLAIM FOR COLLATERAL COMPENSATION PENDING, IDENTIFY THE
ENTITY AGAINST WHICH A CLAIM WAS MADE
UPON THE SUBMISSION OF THIS CLAIM, THE CLAIMANT WAIVES THE RIGHT TO FILE A CIVIL
ACTION (OR TO BE A PARTY TO AN ACTION) IN FEDERAL OR STATE COURT FOR DAMAGES
SUSTAINED AS A RESULT OF THE TERRORIST RELATED AIRCRAFT CRASHES OR SEPTEMBER 11, 2001.
15. RELEASE: THE INFORMATION PROVIDED IN THIS STATEMENT OF CLAIM AND ANY
ATTACHMENTS, AND ANY MATERIAL INFORMATION SUBMITTED BEFORE OR AFTER THIS
STATEMENT OF CLAIM IN REGARD TO OR IN SUPPORT OF THE CLAIM, WILL BE USED ONLY BY THE
DEPARTMENT TO DECIDE YOUR CLAIM. BY YOUR SIGNATURE ON THIS STATEMENT OF CLAIM,
YOU ACKNOWLEDGE THAT YOU ARE AWARE OF AND AGREE TO THIS DISCLOSURE POLICY, AND
YOU AUTHORIZE THE DEPARTMENT AND ITS STAFF TO CONDUCT ANY INVESTIGATION AND/OR
AUDIT NEEDED TO DECIDE YOUR CLAIM.
16. CERTIFICATION
I, , CERTIFY THAT
(Type or print your name)
I AM AUTHORIZED TO MAKE THIS CERTIFICATION ON BEHALF OF THE CLAIMANT.
(STATE YOUR RELATIONSHIP TO CLAIMANT: )
I FURTHER CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE STATEMENTS SET
FORTH IN THIS STATEMENT OF CLAIM, INCLUDING ANY PAPERS ATTACHED TO OR FILED WITH THE
STATEMENT OF CLAIM, ARE TRUE AND ACCURATE, AND THAT ALL MATERIAL FACTS HAVE BEEN
SET FORTH IN THIS STATEMENT OF CLAIM.
(7)
DATE SIGNATURE
COUNTY OF _________________________________
STATE OF ____________________________________
Sworn and subscribed to before me this day of , 200
NOTARY PUBLIC
PENALTIES
YOUR ATTENTION IS DIRECTED TO THE FEDERAL LAW ON FALSE STATEMENTS, 18 U.S.C. SECTION 1001,
WHICH PROVIDES:
"WHOEVER, IN ANY MATTER WITHIN THE JURISDICTION OF ANY DEPARTMENT OR AGENCY OF THE
UNITED STATES, KNOWINGLY AND WILLFULLY FALSIFIES, CONCEALS OR COVERS UP BY ANY
TRICK, SCHEME, OR DEVICE A MATERIAL FACT, OR MAKES ANY FALSE, FICTITIOUS OR
FRAUDULENT STATEMENTS OR REPRESENTATIONS, OR MAKES OR USES ANY FALSE WRITING OR
DOCUMENT KNOWING THE SAME TO CONTAIN ANY FALSE, FICTITIOUS OR FRAUDULENT
STATEMENT OR ENTRY, SHALL BE FINED NOT MORE THAN $10, 000 OR IMPRISONED NOT MORE
THAN FIVE YEARS, OR BOTH."
MAIL THIS FORM TO:
911 VICTIM COMPENSATION
U.S. DEPARTMENT OF JUSTICE
WASHINGTON, DC 20530
BE SURE TO ATTACH DOCUMENTS TO HELP PROVE YOUR CLAIM.
NOTE: EACH DOCUMENT IN A FOREIGN LANGUAGE MUST BE ACCOMPANIED BY A VERIFIED ENGLISH
TRANSLATION.
IF YOU HAVE ANY QUESTIONS REGARDING THE COMPLETION OF THIS FORM, PLEASE CALL: