Notice of Filing Claim

U.S. Victims of State Sponsored Terrorism Fund
Notice of Filing Claim
OMB No. 1123-0013
Expires XX/XX/XXXX

Instructions to the Decedent Victim’s Personal Representative:
You are required to notify all living relatives and potentially interested parties, as listed below, that you are
filing a claim on behalf of the decedent Victim. Follow the instructions below:
1. Complete Part V of the Application Form by following the instructions for that Part. You are
required to list in Part V of the Application Form and deliver a copy of this Notice to the following
people:
 The immediate family of the decedent Victim (the spouse, former spouse(s), children, other
dependents, siblings, and parents);
 The Executor or Administrator and beneficiaries of the decedent Victim’s will;
 The beneficiaries of the decedent Victim’s life insurance policies; and
 Any other person who may reasonably be expected to assert an interest in an award or to
have a cause of action to recover damages relating to the wrongful death of the decedent
Victim.
2. Fill out a separate copy of the Notice provided on the next page for each person to whom you are
required to provide a Notice of Filing Claim as listed in Part V of the Application Form. Fill out the
name and address of the person to whom you are providing the Notice and insert the name of the
decedent Victim in the spaces provided below as indicated. You must provide this Notice* to all
living relatives and potentially interested parties, regardless of whether or not they are or will be
included in the Proposed Distribution Plan.
3. Deliver each Notice personally or by certified mail, return receipt requested. Make a copy of the
Notice for your records prior to delivery.
4. Complete the date and method of delivery for each individual in either the appropriate fields in
Part V of the Application Form or in the List of Individuals Notified of Claim Filing form.
__________________________________________________________________________________________
* The Personal Representative must notify everyone specified in Part VII.2 of the U.S Victims of State
Sponsored Terrorism Fund’s Notice published in the Federal Register (Justice for United States Victims of
State Sponsored Terrorism Act, 81 Fed. Reg. 45538 (July 14, 2016)). You do not have to use this particular
Notice of Filing Claim; however, any other notification must meet all of the requirements in Part VII.2 of the
Federal Register Notice.

October 2016 Version 2.0

U.S. Victims of State Sponsored Terrorism Fund
Notice of Filing Claim
OMB No. 1123-0013
Expires XX/XX/XXXX

To:
Name:
Address:

You are receiving this Notice to inform you that a claim on behalf of ________________________
(insert name of decedent Victim) is being filed with the U.S. Victims of State Sponsored Terrorism Fund (“the
Fund”). The claim is being filed by ____________________________________ (insert name of Personal
Representative).
The rules that govern the Fund state that only one claim may be filed in connection with the death of a
decedent Victim and that the claim must be filed by the decedent Victim’s Personal Representative. The rules
also state that any payment from the Fund shall be paid to the Personal Representative and that the Personal
Representative is required to distribute the award among the decedent Victim’s beneficiaries in accordance with
the laws of the decedent Victim’s domicile.
The Personal Representative is informing you that a claim is being filed on behalf of
_______________________ (insert name of decedent Victim) because the Personal Representative is required
to give notice of claim filing to the decedent Victim’s immediate family; to the Executor, Administrator, and
beneficiaries of the decedent Victim’s will; the beneficiaries of the decedent Victim’s life insurance policies; and
to other people who might reasonably be expected to assert an interest in an award or to have a cause of action
to recover damages relating to the wrongful death of the decedent Victim.
You are not required to take any action in response to this Notice. However, any objection to the filing
of the claim must be made within 30 days after the claim has been filed, which could be as soon as 30 days from
the date this Notice was mailed or otherwise provided to you.
If you want to learn more about the Fund, please visit the Fund’s website at www.usvsst.com or call toll
free (855) 720-6966; outside the U.S., please call (614) 553-1013.
Dated: __ /__ /____
mm/dd/yyyy

From the Personal Representative:
Name:
Address:

October 2016 Version 2.0