Fill and Sign the Emergency Intake Form

OMB Number 1105-0077 U.S. Department of Justice Victim Compensation Fund P. O. Box 18698 Washington, D.C. 20036-8698 Dear Objector: In order for us to be able to evaluate your objection or statement of interest, please complete the information requested in the attached Objection/Statement of Interest Form, sign it, make a copy for your files, and mail the original signed form to the address shown above. Please send your objection/statement of interest to us as soon as possible so it may be considered. Please use the Objection/Statement of Interest Form below to facilitate this process. If your form is not sent to us in a timely manner, the claim you are objecting to or have an interest in may be processed before we receive your form, which at that time it will be withdrawn from consideration. Before you complete the Objection/Statement of Interest Form, you should be aware of the following important points. Please read these carefully before you decide how you wish to proceed: • First, only one claim is to be submitted on behalf of a deceased victim, and that claim is to be submitted by the person determined by the Special Master to be the “Personal Representative.” The Special Master believes that, in most cases, this person should normally be the individual appointed by a court as the “executor” or “administrator” or the “Personal Representative” of the decedent’s will or estate. In certain instances, the Special Master does have discretion to designate the Personal Representative if the applicant is the person named in the decedent’s will as the executor or administrator, or if the applicant is the first person in the line of succession established by the laws of the state of the decedent’s domicile if the victim died without a will. • Second, the Personal Representative who files a claim on behalf of a deceased victim is not necessarily the person who is entitled to the award. Rather, the Personal Representative is under an obligation to distribute the award in a manner consistent with the law of the decedent’s domicile or any applicable ruling made by a court of competent jurisdiction or as provided by the Special Master. For example, a surviving spouse appointed by a State court as Administrator of the estate may be the Personal Representative who submits a single claim under the Fund, but he or she is required to distribute any award to any other relatives or beneficiaries entitled to receive part of the award. In some cases, the Special Master may make provision for separate distributions to comply with an approved distribution plan. An example would be payments to a minor. • Third, the regulations provide that the Personal Representative shall provide to the Special Master a plan for distribution of any award received from the Fund before final payment is authorized. Any third party may provide a suggestion regarding the distribution plan. In the event the Special Master concludes that the Personal Representative’s plan for distribution does not appropriately compensate the victim’s spouse, children, or other relatives, the Special Master may direct the Personal Representative to distribute all or part Page 1 of 5 OMB Number 1105-0077 of the award to such spouse, children or other relatives. • Fourth, if you were dependent on the victim, but not formally claimed on the victim’s tax return you may be eligible for an additional award if you could have been claimed as dependent. The Special Master will use the Internal Revenue Service's definition of dependency to determine if you could have been claimed as dependent. Please refer to IRS Publication 501, Exemptions, Standard Deductions, and Filing Information, included with this letter, for more information on who qualifies as a dependent. • Fifth, you should be aware that the Special Master is not required to arbitrate, litigate, or otherwise resolve any dispute as to the identity of the Personal Representative. In the event of a dispute over the appropriate Personal Representative, the Special Master may suspend adjudication of the claim or, if sufficient information is provided, calculate the appropriate award and authorize payment, but hold any payment until the dispute is resolved either by agreement of the disputing parties or by a court of competent jurisdiction. Alternatively, the disputing parties may agree in writing to the identity of a Personal Representative to act on their behalf, who may seek and accept payment from the Fund while the disputing parties work to settle their dispute. After reviewing the above information, please complete the enclosed Objection/Statement of Interest Form indicating whether you still wish to proceed with an objection/statement of interest and, if so, the reason for your objection/statement of interest. Note: If you wish to withdraw or limit an objection you should still complete and return the Objection/Statement of Interest Form indicating that you do not wish to object. You can instead complete a statement of interest to the Special Master setting forth, for example, your own particular circumstances, relation to the Victim, and/or interest in any award. Finally, you will need to sign an authorization for release of information. Then, please mail or fax the completed form to the following address: Via regular mail: Via overnight mail: Victim Compensation Fund P.O. Box 18698 Washington, DC 20036-8698 Victim Compensation Fund 1900 K Street, NW Suite 900 Washington, DC 20006 202-822-4485 Fax – (703) 741-1273 Please contact the help line at 888-714-3385 if you have any questions. Paperwork Reduction Act Notice. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it contains a currently valid OMB approval number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you. The estimated average time to complete and file this application is 2 hours. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office of the Special Master, U.S. Department of Justice, 950 Pennsylvania Ave, NW, Washington, DC 20530; OMB No. 1105-0077. (Do not mail your completed form to this address.) Page 2 of 5 OMB Number 1105-0077 th September 11 Victim Compensation Fund of 2001 Objection/Statement of Interest Form Person’s Name: Person’s Address: Person’s Telephone Number(s): Victim’s Name: Person’s Relation to Victim: __________________________________________ Name of purported Personal Representative: I hereby formally withdraw any objection I have previously made to the filing of a claim by on behalf of . If you do not object to the authority of the Personal Representative to file a claim, you may still submit a statement of interest to the Special Master. Check here if you are doing so. I object to the authority of to act as the Personal Representative to file the claim with the Victim Compensation Fund on behalf of . The reason(s) for my objection are as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________ (Attach additional pages if necessary.) I object to the filing of any claim on behalf of the Victim Compensation Fund. with The reason(s) for my objection are as follows: _________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________ (Attach additional pages if necessary.) I wish to provide a statement of interest to the Special Master with respect to my relationship to the victim, my interest in an award, any proposed distribution plan, or any other matter: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________(Attach additional pages if necessary) I wish to claim that I qualify as dependent under the Internal Revenue Service’s definition of dependency. I understand that I may have to submit additional documentation to support that I would have qualified as a dependent. Page 3 of 5 OMB Number 1105-0077 th September 11 Victim Compensation Fund of 2001 Objection/Statement of Interest Form I hereby certify that the information I provided in this form is true and accurate to the best of my knowledge. Further, I understand that false statements or claims made in connection with this form may result in fines, imprisonment, and/or any other remedy available by law to the Federal government. _______________________________ Signature Privacy Act Notice The Department of Justice is authorized to collect this information by the September 11th Victim Compensation Fund of 2001, Title IV of Public Law 107-42, Stat.230 (“Air Transportation Safety and System Stabilization Act.”). The information you submit in your objection/statement of interest is for official use by the U.S. Department of Justice for the purposes of determining the validity of your objection/statement of interest. Provision of this information is voluntary; however, failure to provide complete information may result in a denial of your objection/statement of interest. Information you submit regarding your objection/statement of interest may be disclosed by the Government only in accordance with the provisions of the Privacy Act. Page 4 of 5 OMB Number 1105-0077 th September 11 Victim Compensation Fund of 2001 Objection/Statement of Interest Form Authorization for Release of Information Carefully read this authorization to release information, then sign and date it in ink. I Authorize the U.S. Department of Justice to obtain any information relating to my objection or statement of interest under the September 11th Victim Compensation Fund of 2001 (Compensation Fund) from individuals or other sources having information relating to my objection or statement of interest. I Further Authorize the U.S. Department of Justice to disclose any records or information relating to my objection or statement of interest to: The Personal Representative who made the claim to which I am objecting; agency contractors assisting in the administration of the Compensation Fund; other federal, state, or local agencies; and other individuals or entities having information related to the objection or statement of interest. I Further Authorize the U.S. Department of Justice to publish the name of the person who has filed this objection or statement of interest and the name of the victim to whom it relates. I Further Authorize the release of information relating to my objection or statement of interest where such information indicates a violation or potential violation of law, including submission of fraudulent claims, to any civil or criminal law enforcement authority or other appropriate agency charged with responsibility of investigating or prosecuting such a violation. I Further Authorize individuals having information pertinent to my objection or statement of interest to release such information to a duly accredited representative of the Department of Justice during the review of my objection or statement of interest to the Compensation Fund, regardless of any previous agreement to the contrary. Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for five (5) years from the date signed or upon my written termination whichever is sooner. I Certify that I am the person named below and I authorize the release of information listed above. ____________________________________ Name (please print first, middle and last) Signature Date Page 5 of 5