Date
App. Rec’d.__________
Date
all Supporting Docu-
mentation
Rec’d.__________
ITVERP
Claim Number:
________________________
asdf
U.
S. Department of Justice
Office
of Justice Programs
Office
for Victims of Crime
OMB Number 1121-XXXX
Expiration: XX/XX/XX
For Official Use Only
International Terrorism Victim Expense Reimbursement Program Application
Please type or print clearly. Attach additional paper, if necessary.
A.
Application Type
Check only one. (Reminder: All applications must include an original signature and original receipts.)
_____Itemized Application
_____Interim Emergency Payment Application
_____Supplemental Application (If a Supplemental Application, provide Original Claim Number:_____)
B.
Victim Information
To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.
Please provide the following personal information on the victim:
Victim’s Full Name (First, Middle, Last):________________________________________________
Street Address: __________________________________________________________________
City/State/Zip: _______________________________ Country: ___________________________
Telephone: ____________________ Fax: ____________________
E-mail (optional): _______________
Date of Birth: _______________ SSN/EIN/Other Identification Number (if applicable): ___________
Gender:____ Male ____ Female Place of Birth:____________ Country of Citizenship:___________
Employer (if applicable): ___________________________________________________________
Employer Street Address:___________________________________________________________
City/State/Zip: _______________________________ Country: ___________________________
Contact Person (if known): _______________ Telephone: ______________ Fax: ______________
Contact Person’s E-mail (optional): ___________________________________________________
Victim’s known children, dependents, or recipients of support (continue on Supplemental Sheet, under Section B-1):
Name: ______________________________ DOB:__________ Relationship: _______________
Do you know of anyone else who may be eligible for expense reimbursement under this program who is not party to this application? ____ Yes ____ No
If Yes, please list all (additional information may be listed on the Supplemental Sheet in Section B-2):
Name: _________________________________ Relationship: ____________________________
Full Address: ___________________________________________________________________
Telephone: ______________ Fax: _____________ E-mail (optional): ________________________
B.
Victim Information (Continued)
Check
all that apply
Victim Eligibility:
____ United States Citizen/National
____ United States Government Officer
____ United States Government Employee:
____ Foreign Service National
____ Foreign Service Officer
____ Civil Servant
____ Other:_________________________
Is the Victim: ____ Deceased ____ Minor ____ Incapacitated ____Incompetent
(If the victim is deceased, a minor, incapacitated, or incompetent, please go directly to Section C. If the victim is none of these, please skip Section C and go directly to Section D.)
C.
Claimant Information
Please provide the following information on the Claimant.
(This section should be completed only if filing on behalf of a victim. If the victim and the claimant are the same person, applicant may proceed directly to Section D.)
Claimant’s Full Name (First, Middle, Last):_____________________________________________
Street Address: __________________________________________________________________
City/State/Zip: _______________________________ Country: ___________________________
Telephone: ______________ Fax: ______________ E-mail (optional): _______________________
Date of Birth: ____________ SSN/EIN/Other Identification Number (if applicable): ______________
Gender: ____ Male ____ Female Country of Citizenship: ________________________
Relationship to Victim: ( ) Spouse ( ) Child ( ) Parent ( ) Sibling ( ) Representative
( ) Other:________________________________________________
D.
Crime Information
Please provide the following information about the act of international terrorism:
Date of crime: ________________________
Location of crime (include City and Country): ____________________________________________
Description of crime: ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Injuries to victim as a result of the crime: ____Physical ____Emotional ____ Property
Describe injuries: ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
Lead investigative agency (if known): _________________________________________________
E.
Expenses
To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.
Please check all applicable expenses or losses for which you are seeking reimbursement or payment from OVC. You may include associated travel expenses for any of the following categories.
____ Medical Expenses (including Dental and Rehabilitation Costs) $___________
____ Mental Health Care Services $__________
____ Property Loss, Repair, and Replacement $__________
____ Funeral and Burial Expenses $__________
____ Misc. Expenses (e.g., temp. lodging, local transportation, telephone costs, emerg. travel) $_______
Total Amount Requested $_______
Do you anticipate incurring additional cost(s) related to this act of international terrorism which may result in a claim for additional reimbursement or payment? ____ Yes ____ No
F.
Collateral Sources (Other Sources of Financial Help)
To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.
Do you currently have any other source(s) of financial help or aid that may cover any of your expenses?
____ Yes ____ No
If Yes, please acknowledge all of the potential sources of reimbursement or payment applied for or received in relation to this crime:
____ Medical/Health Insurance ____ Disability Insurance
____ Medicare/Medicaid ____ Vocational Rehabilitation Benefits
____ Property/Auto Insurance ____ Homeowners/Renters Insurance
____ Military/Veterans’ Benefits ____ Restitution
____ Funeral/Burial Insurance ____ Payments/Compensation by Local, State,
____ Other (please list):__________________ State VOCA, Federal, and/or Foreign
______________________________________ Governments
Have you previously received any funds from, or have any of your expenses been paid by, the U.S. Department of Justice (such as the Office for Victims of Crime or the FBI) or its Contractor?
____ Yes____ No If Yes, how much? $________ For what? ____________________
Please provide additional information on all of the above sources checked or received/identified (continue on Supplemental Sheet, Section F):
Source: __________________________________ Policy No. (if applicable): _________________
Company (if applicable): ___________________________________________________________
Telephone: ______________ Fax: ______________ E-mail (optional): _______________________
Name of Individual Reimbursed: ____________________________ SSN: ___________________
Status of Application:
____ Application Pending
____ Application Approved; Amount $__________
____ Application Denied. If declined, please indicate reason: _____________________________
F.
Collateral Sources (Other Sources of Financial Help) (Continued)
Any unsatisfied judgment against a foreign government will be considered a collateral source, and your ITVERP reimbursement will be reduced accordingly, unless you agree to NOT sue the United States government for satisfaction of that judgment by signing and dating the following:
I waive any right I may have to sue the United States government for satisfaction and enforcement of my unsatisfied judgment against the foreign government for the act of terrorism for which I am claiming reimbursement from ITVERP.
Name Date
G.
Service Provider Information
To help process your application more quickly, please consult the Application Instructions for information on the required documents to be included with your application.
Please supply the following information on individuals or agencies that provided services related to the act of international terrorism to the victim (continue on Supplemental Sheet, Section G).
Name of service provider: __________________________________________________________
Street address: __________________________________________________________________
City/State/Zip: ______________________________ Country: ____________________________
Telephone: ______________ Fax: ______________ E-mail (optional): _______________________
Type of service provided:___________________________________________________________
Cost of service(s) rendered $________ Diagnosis or Condition: ________________________
Are services ongoing? ____Yes ____ No
If services are ongoing, how long will they continue? ______________________________________
Were you billed for the cost of the services? ____ Yes ____ No
Were the costs paid in full? ____ Yes ____ No If Yes, full amount paid $________
Were the costs paid in part? ____ Yes ____ No If Yes, partial amount paid $________
By whom were either the full or partial payments made? ___________________________________ ______________________________________________________________________________
Name/Telephone/Fax/E-mail (optional)/Claim Number (if applicable)
H.
Authorization, Consents and Certifications
This release must be signed and dated for the ITVERP to consider your application for expense reimbursement.
I agree to contact and repay the ITVERP if I receive any payments from the persons or governments responsible for the act of international terrorism, a civil lawsuit, an insurance policy, or any other government or private agency to cover expenses for which I have already received payment from this program.
I hereby authorize any hospital, physician, funeral director, municipal authority, employer or union, insurance company, social service bureau, Social Security office, or any other person, firm, agency, or organization to furnish to the Office for Victims of Crime, ITVERP, or its representatives, any information requested, including medical records, diagnostic assessments, and mental health evaluations, needed to complete my claim for expense reimbursement. A photocopy of this authorization shall be considered as effective and valid as the original.
I hereby certify, subject to the penalty of fine or imprisonment or both, that I have provided all names and addresses of all other individuals who may be eligible to receive expense reimbursement in relation to the victim in this case, and I further certify that I have notified these individuals in writing, either by certified mail or hand delivery, that I have filed a claim for expense reimbursement in relation to the victim.
I hereby certify, subject to the penalty of fine or imprisonment or both, that I am neither directly nor indirectly responsible for the terrorist act or mass violence for which I am seeking expense reimbursement.
I hereby certify, subject to the penalty of fine and imprisonment, that the information contained in the application for terrorism victim expense reimbursement is true and correct to the best of my knowledge.
_______________________________________________ ________________________________
Applicant’s Signature Date
_______________________________________________ ________________________________
Representative’s Signature (or signature of individual Date
who assisted in the preparation of this application)
[Last Updated: 08/24/06 baw]
Page
File Type | text/rtf |
File Title | Date App |
Author | td50621a |
Last Modified By | walkerb |
File Modified | 2006-08-24 |
File Created | 2006-08-24 |