3 Death Benefit Certification of Relationship Survivor

OMB No. 0915-0334

Exp. XX/XX/20XX

Countermeasures Injury Compensation Program (CICP)

Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient

Case Number: [CICPXXXXXXXXXX]

This Certification will assist the Countermeasures Injury Compensation Program (CICP) in determining benefits. Please complete the statement below that applies to your case, and print and sign your name below. For guidance on which statement to complete, see the letter detailing the information the CICP needs to determine your benefits. Potentially eligible survivors are listed on the CICP letter dated [insert date], under: “Categories of Eligible Survivors and the Order of Priority for Payments of Death Benefits”.

Option 1

I certify that I am the _________________________________________________

(state your relationship to the survivor, e.g. wife, mother, daughter, etc.)

of[recipient name] and there are no other eligible survivors.

Option 2

I certify that I am the _________________________________________________

(state your relationship to the survivor, e.g. wife, mother, daughter, etc.)

Of [recipient name] and there are other eligible survivors.

Please list other eligible survivors and their relationship to [recipient name]. If you need more space, attach a separate sheet of paper that lists additional eligible survivors and their relationship to [recipient name].

1. ____________________ _________________________

2. ____________________ _________________________

3. ____________________ _________________________

4. ____________________ _________________________

5. ____________________ _________________________

By signing this form, I hereby certify that the information provided in this Certification is true and accurate to the best of my knowledge. Further, I understand that false statements or claims made in connection with this Certification, including subsequent information and documentation submitted in connection with this Certification, may result in any remedy, including civil remedies, available by law to the United States. I will provide updated information (including, but not limited to medical records, employment income records, and change of address) until the Program has made its final benefits decision.

______________________________ _______________________________

Name of Requester (Please print) Name of Representative (if applicable)

____________________________ ___________________

Signature of Requester or Representative Date

Public Burden Statement: The purpose of this data collection is to gather information to allow the Secretary of Health and Human Services to determine if requesters are eligible for Countermeasure Injury Compensation Program (CICP) benefits. Requesters (or their representatives) must submit appropriate documentation forms and relevant medical records as specified in Section 42 CFR 110.50-110.53 to the CICP. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0334 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 CFR Part 110). Access to these records is strictly limited to authorized users who are aware of their responsibilities under the Privacy Act and who are required to maintain Privacy Act safeguards with respect to such records. The System of Records Notice for Injury Compensation Programs, HHS/HRSA/HSB, System No. 09–15–0056, identifies authorized users. Public reporting burden for this collection of information is estimated to average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.