Date
App. Rec’d.__________
Date
all Supporting Docu-
mentation
Rec’d.__________
ITVERP
Claim Number:
________________________
U.
S. Department of Justice
Office
of Justice Programs
Office
for Victims of Crime
OMB Number 1121-0309
Expiration: 04/30/10
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 filling out a Supplemental Application, provide Original Claim Number: _____)
B.
Victim Information
To help process your application more quickly, please read 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: _______________
Please Complete One:
Social Security Number: _______________
Employee Identification Number: ____________
Other Identification Number (e.g., passport, driver’s license, etc.): _______________
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 listed on 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, the 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: ____________
Please Complete One:
Social Security Number: _______________
Employee Identification Number: ____________
Other Identification Number (e.g., passport, driver’s license, etc.): _______________
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): ____________________________________________
Briefly describe crime (Use Supplemental Attached Form, if needed): __________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
Injuries to victim as a result of the crime: Physical____ Emotional____ Property____
Briefly describe injuries (Use Supplemental Attached Form, if needed): ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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 related travel expenses for any of the following categories.
____ Medical Expenses (including dental and rehabilitation costs) ___________
____ Mental Health Care Services __________
____ Property Loss, Repair, and Replacement __________
____ Description of Property Loss: _______________________________________________________ ________________________________________________________________________________________________________________________________________________________________
____ Funeral and Burial Expenses __________
____ Miscellaneous Expenses (e.g., temporary lodging, local transportation, telephone costs, emergency 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____
*Please note that it is not required to convert expenses to U.S. dollars.
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, (or in the past had) any other source(s) of financial help that may cover your expenses? Yes____ No____
If “yes”, please acknowledge all of the 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 ____ Emergency Assistance Programs
____ Other (please list):__________________
______________________________________
Have you previously received any funds from, or have any of your expenses been paid for the victim on this form by, the U.S. Department of Justice (or any of its bureaus or offices such as the Office for Victims of Crime or the FBI) or it’s Emergency Assistance Programs?
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 Number. (if applicable): _________________
Company (if applicable): ___________________________________________________________
Telephone: ______________ Fax: ______________ E-mail (optional): _______________________
Name of Individual Reimbursed: ____________________________
Please Complete One:
Social Security Number: _______________
Employee Identification Number: ____________
Other Identification Number (e.g., passport, driver’s license, etc.): _______________
Status of Collateral Sources:
____ Claim Pending; Amount ___________
____ Claim Approved; Amount __________
F.
Collateral Sources (Other Sources of Financial Help) (Continued)
Any unsatisfied judgment against a foreign government will be considered a collateral source of financial help, 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 to the victim related to the act of international terrorism (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 before your application can be considered for expense reimbursement.
I agree to contact and repay 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 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.
_______________________________________________ ________________________________
Victim/Claimant’s Signature Date
_______________________________________________ ________________________________
Representative’s Signature (or signature of individual Date
who assisted in the preparation of this application)
Street Address: ___________________________________
City/State/Zip: ____________________________________
Telephone: _______________________________________
Email Address: ____________________________________
Page
File Type | text/rtf |
File Title | Date App |
Author | td50621a |
Last Modified By | SlaughtC |
File Modified | 2010-01-08 |
File Created | 2010-01-08 |