Guam Claim Form - English Version

OMB Approval Number:
Expiration Date:

U.S. DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION

(FOR FCSC USE ONLY)
CLAIM NO.

STATEMENT OF CLAIM
FOR FILING OF CLAIMS IN THE GUAM CLAIMS PROGRAM PURSUANT TO
THE GUAM WORLD WAR II LOYALTY RECOGNITION ACT, TITLE XVII,
PUBLIC LAW 114-328 (DECEMBER 23, 2016)
CONTACT INFORMATION
1. CLAIMANT
Name of Claimant
(Last)

(First)

(Middle)

(Street Address)
(City)

(State/Territory)

Work Phone

(Zip Code)

Home Phone

Email
Date of Birth
2. LEGAL REPRESENTATIVE (if any)
Name of Legal Representative
(Last)

(First)

(Middle)

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. XXXXXXXX). 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-GUAM

3. TYPE OF CLAIM

BASIC CLAIM INFORMATION

I hereby submit a claim for payment under the Guam World War II Loyalty Recognition Act, Title XVII, Public Law 114-328 (December 23,
2016) as a: (check all that apply)
Survivor of a Compensable Guam Decedent (Claimant is a spouse, child or parent of an individual who died as a result of the attack/
occupation/liberation of Guam)
Compensable Guam Victim (Claimant suffered at least one of the following as a result of the attack/occupation/liberation of Guam:
hiding to evade internment, internment, forced march, forced labor, personal injury, severe personal injury, or rape)
4. GUAM RESIDENCY
Have you ever been a resident of Guam?
If the above answer is "Yes," please provide the date(s) of residency (from/to).

5. CLAIM OF SURVIVOR OF COMPENSABLE GUAM DECEDENT
Complete this Section only if you are submitting a claim as a Survivor of a Compensable Guam Decedent.
5.1 Are you a spouse, child, or parent of an individual who died as a result of the attack and occupation of Guam by Imperial
Japanese military forces during World War II, or incident to the liberation of Guam by United States military forces? If so, please
respond to each question below.
5.2 Name of decedent

5.3 Date of death

5.4 Relation to decedent
5.5 Was the decedent a resident of Guam?
5.6 If the answer above is "Yes," please provide the date(s) of residency (from/to).

5.7 Identify all known survivors of the decedent who were living as of December 23, 2016, including, to the extent applicable, the
decedent's spouse, children, and parents.

5.8 Please provide as detailed an account as you recall of the facts and circumstances relating to the decedent's death. Please specify the
cause of the decedent's death, if known. You may also attach any other evidence that you believe supports your answers to the above
questions. (Attach additional pages as necessary)

6. CLAIM OF COMPENSABLE GUAM VICTIM
Complete this Section only if you are submitting a claim as a Compensable Guam Victim.

6.1 Hiding To Evade Internment
6.1.1 Did you hide to evade internment, as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.1.2 Please provide the approximate date(s) and location(s) of your hiding.

6.1.3 Please provide a detailed account of the facts or circumstances relating to your hiding and describe the conditions you experienced
while in hiding. (Attach additional pages as necessary)

6.2 Internment
6.2.1 Were you interned as a result of the attack and occupation of Guam by Imperial Japanese military forces during World War II,
or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.2.2 Please provide the approximate date(s) and location(s) of your internment.

6.2.3 Please provide a detailed account of the facts or circumstances relating to your internment and describe the conditions you experienced
while interned. (Attach additional pages as necessary)

6.3 Forced March
6.3.1 Were you a victim of forced march as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.3.2 Please provide the approximate date(s) and location(s) where the forced march took place.

6.3.3 Please provide a detailed account of the facts or circumstances that resulted in the forced march and describe the conditions you
experienced. Please specify the food, water, and clothing rations you received, the number of hours you were required to walk every day,
and the provisions made for overnight or temporary accommodation. (Attach additional pages as necessary)

6.4 Forced Labor
6.4.1 Were you a victim of forced labor as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.4.2 Please provide the approximate date(s) and location(s) where labor was performed.

6.4.3 Please provide your age at the time the labor was performed.
6.4.4 Did you receive compensation for your labor?
6.4.5 Please provide a detailed description of the type of labor that you performed and the conditions you experienced at your place(s) of
labor. Please specify whether your labor had direct relation to war operations. (Attach additional pages as necessary)

6.5 Personal Injury
6.5.1 Did you suffer a personal injury as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.5.2 Please identify the injury that you suffered (check all that apply) and provide the date and place of injury. If your injury is not listed,
please enter it in the space provided at the end of the chart below.
Type of Injury

Approximate Date of Injury

Place of Injury

Dismemberment
Loss of Limb
Paralysis
Disfigurement
Burns
Scarring

Other (Please Specify)
Other (Please Specify)
6.5.3 Please provide a detailed description of the nature and extent of your injury, the cause of your injury (if known), and the circumstances
under which it occurred. You may also attach to this claim form any other evidence, including photographic evidence, that you believe
supports your answers to the above questions. (Attach additional pages as necessary)

6.5.4 Did your injury require treatment?
6.5.5 If the answer is "Yes," where were you treated and what kind of treatment did you receive?

6.6 Rape
6.6.1 Were you the victim of rape as a result of the attack and occupation of Guam by Imperial Japanese military forces during World
War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.6.2 Please provide the approximate date(s) and location(s) of your injury.

6.6.3 Please provide a detailed account of your injury and the facts and circumstances relating to it. (Attach additional pages as necessary)

6.7 Level of Payment Sought
Please specify the level of payment sought for your Compensable Guam Victim claim.

7. PRIOR RECEIPT OF COMPENSATION
Have you or anyone else received any compensation from any source with respect to the subject matter of this claim,
including amounts paid under the Guam Meritorious Claims Act of 1945 (Public Law 79-224)?
If the answer is "Yes," state the date of receipt, source, and amount of compensation.

8. NOTICE OF DISCLOSURE
The information provided in this Statement of Claim and in any attachments, and 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, 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,
including via the Internet.
9. SIGNATURE AND AFFIDAVIT
NOTE--This Statement of Claim must be signed in the presence of a legally-commissioned notary public.
I,

, do solemnly swear (or affirm), under penalty of

perjury, that the answers that I have provided to the questions set forth in this Statement of Claim, and any attachments hereto, are true and
correct, and made with full knowledge of the fact that penalties involving fines and imprisonment are prescribed by various statutes of the
United States for making a false statement.

Date

Signature of Claimant

SUBSCRIBED and SWORN TO (or AFFIRMED) before me this ______ day of ____________________, 201__.
At _______________________________________ ___________________________________________
(City)
(State or Territory)

___________________________________________
NOTARY PUBLIC
My commission expires: ______________________

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Privacy Act Statement
The Foreign Claims Settlement Commission (the Commission) is authorized to collect the information requested on this form (or requested at any other time
regarding this claim) under P.L. 114-328 §1705. The information collected will be used to enable the Commission to carry out its statutory responsibility to
determine the validity and amount of the claims submitted to it under P.L. 114-328 §1705. 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 may be
disclosed pursuant to routine uses, published at 82 Fed. Reg. 21264 (May 5, 2017). Such routine uses include:
·
To the Department of the Treasury in connection with the 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 the Commission, or 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.