VCF Claim Form

OMB 1105-0092

Under the James Zadroga September 11 Health and Compensation Act of 2010 (P.L. 111-347), the Department of Justice would request biographical information and limited information regarding eligibility for the September 11th Victim Compensation Fund from potential claimants in order to begin the process of determining whether claimants will be eligible for compensation from the Fund.

The latest form for VCF Claim Form expires 2022-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 1105-0092 VCF Claim Form Form
1105-0092 _SS PRA - Revised EC_Form_FINAL_041316_.docx Supporting Statement A
Published 30 Day.pdf Supplementary Document
VCF Updated Claim Form - Summary of Changes_1105-0092.docx Justification for No Material/Nonsubstantive Change
1105-0092_Claim Form_Signature Page_041316.docx Supplementary Document
1105-0092_Exhibits_Final Copy_041316.pdf Supplementary Document
1105-0092 OMB Form 83-I - REVISED_041316.pdf Supplementary Document
VCF Claim Form Form

All Historical Document Collections

201907-1105-001 Approved without change	Extension without change of a currently approved collection	2019-07-24
201906-1105-001 Improperly submitted and continue	No material or nonsubstantive change to a currently approved collection	2019-06-21
201604-1105-001 Approved without change	Reinstatement with change of a previously approved collection	2016-04-14
201201-1105-003 Approved without change	Extension without change of a currently approved collection	2012-04-18
201201-1105-002 Approved with change	Revision of a currently approved collection	2012-01-12