FCSC 1-08 Statement of Claim

OMB Approval Number
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION

(FOR FCSC USE ONLY)
CLAIM NO. LIB I -

STATEMENT OF CLAIM
FOR FILING OF CLAIMS IN THE LIBYA CLAIMS PROGRAM PURSUANT TO THE LIBYAN
CLAIMS RESOLUTION ACT OF AUGUST 4, 2008, Pub. L. 110-301, THE CLAIMS SETTLEMENT
AGREEMENT BETWEEN THE UNITED STATES AND LIBYA DATED AUGUST 14, 2008,
EXECUTIVE ORDER 13477 OF OCTOBER 31, 2008, THE INTERNATIONAL CLAIMS SETTLEMENT
ACT OF 1949, AS AMENDED (22 U.S.C. 1621 et seq.) including 22 U.S.C. 1623(a)(1)(C), AND THE
LETTER OF REFERRAL FROM THE DEPARTMENT OF STATE DATED DECEMBER 11, 2008.
NOTE: Please read the instructions carefully before completing this form. Additional pages may be appended to
this form as necesary.

CONTACT INFORMATION

1. CLAIMANT
Name of Claimant

(Last)

(First)

(Middle)

(Street Address)
(State/Territory)

(City)

(Zip Code)

Home Phone

Work Phone
Email
Name of Injured Party if different from that of claimant
Relation to Injured Party

2. LEGAL REPRESENTATIVE
Name of Lawyer

(Last)

(Middle)

(First)

Name of Law Firm
(Street Address)
(City)
Phone

(State/Territory)

(Zip Code)

Fax

Email
Paperwork Reduction Act Statement: This information collection has been cleared under the Paperwork Reduction Act of 1995, 44 U.S.C. 3501 et seq. (Control
No.
). Under 44 U.S.C. 3506(c)(1)(B)(iii)(V), an agency may not conduct or sponsor, and a person may not be required to respond to, an information collection
request unless the information collection form bears a valid control number. Completion of this form is mandatory in order to obtain compensation. The estimated burden
associated with this collection of information is 2.0 hours per respondent or recordkeeper.

FORM FCSC 1-08
January 2009

BASIC CLAIM INFORMATION
3. U.S. CITIZENSHIP
Please state how and when you acquired U.S. nationality and provide supporting documentation:
By birth in the U.S. - provide the date and place of birth

By naturalization in the U.S. - provide the date and place of naturalization

Other - provide the date on which and the manner by which U.S. nationality was acquired (for example, by birth abroad to U.S.
parents, derivative naturalization, etc.)

4. CLAIMS FOR PHYSICAL INJURY BY PERSONS WHO HAD A LAWSUIT PENDING IN U.S. FEDERAL COURT
4.1 Please identify the litigation or court case in which you were a party.
4.2 Please provide evidence establishing that the injured party was present at the scene of the incident that forms the basis of the litigation.
4.3 Please briefly describe your injuries.

4.4 Was medical treatment received for the injuries described above? If so, please attach supporting documentation.

5. RELEASE AND PENALTIES (Each claimant must sign individually. Please make additional copies of this page as necesary.)

RELEASE: The information provided in this Statement of Claim and any attachments, any material and information

submitted before or after this Statement of Claim in regard to or in support of the claim, will be treated as public information.
The aforementioned information and materials may be made available to interested persons who make inquiries about the
claims program and individual claims filed in the program, in conformity with the Freedom of Information Act. Any
decision issued by the Commission in relation to this Statement of Claim will be made publicly available via the Internet. By
your signature on this Statement of Claim, you acknowledge that you are aware of and agree to the making of such
disclosures, and you authorize the Foreign Claims Settlement Commission and its staff to conduct any investigation needed
to decide your claim.

PENALTIES: Your attention is directed to the federal law on false statements, 18 U.S.C. section 1001, which provides:
[W]hoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United
States, knowingly and willfully–
(1) falsifies, conceals or covers up by any trick, scheme, or device a material fact;
(2) makes any false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially,
fictitious, or fraudulent statement or entry;
shall be fined under [Title 18, U.S. Code] or imprisoned not more than 5 years, or both.

I,

certify that I have read the release and agree to
(Name of Claimant)

its terms. 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 this Statement of Claim, are true and accurate, and that all material facts have
been set forth in this Statement of Claim.
Date

Claimant Signature

Date

Attorney Signature

Privacy Act Statement
The Foreign Claims Settlement Commission (the Commission) is authorized to collect the information requested on this form under 22 U.S.C.
1621 et seq., the Agreement Between the Government of the United States of America and the Great Socialist People's Libyan Arab
Jamahiriya of August 14, 2008 and The Libyan Claims Resolution Act of August 4, 2008, Pub. L. 110-301. The information collected on this
form will be used to enable the Commission to carry out its statutory responsibility to determine the validity and amount of the claims against
Libya submitted to it. Furnishing the requested information to the Commission is voluntary; however, failure to provide such information may
result in either the delay of the adjudication or denial of the claim. Information collected on this form may be disclosed pursuant to routine
uses, published at xx Fed. Reg. xx (xx,xx 2008). Such routine uses include:
• To the Department of State and the Department of the Treasury in connection with the negotiation, adjudication, settlement and payment
of claims;
• To contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative
agreement, or other assignment for the federal government, when necessary to accomplish an agency function related to this system of
records;
• To a Member of Congress or staff acting upon the Member's behalf when the Member or staff requests the information on behalf of, and at
the request of, the individual who is the subject of the record;
• Where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law - criminal, civil,
or regulatory in nature - the relevant records may be referred to the appropriate federal, state, local, territorial, tribal, or foreign law
enforcement authority or other appropriate entity charged with the responsibility for investigating or prosecuting such violation or charged
with enforcing or implementing such law;
• In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the Department of Justice and/or the
Foreign Claims Settlement Commission determines that the records are arguably relevant to the proceeding; or in an appropriate
proceeding before an administrative or adjudicative body when the adjudicator determines the records to be relevant to the proceeding