Fillable ITVERP Application International Terrorism Victim Expense Reimbursement Program (ITVERP) Application

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ITVERP Application International Terrorism Victim Expense Reimbursement Program (ITVERP) Application

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U.S. Department of Justice
Office of Justice Programs
Office for Victims of Crime
OMB Number 1121-0309
Expiration: 3/31/2021
INTERNATIONAL TERRORISM VICTIM EXPENSE REIMBURSEMENT PROGRAM (ITVERP)
ITVERP APPLICATION
ELIGIBILITY: Before you complete the ITVERP application, please consider whether you
or the victim are eligible for the program by answering the following questions:
1) Is the victim a U.S. Citizen or a Foreign Service National who was an employee of (or
contractor with) the U.S. Government at the time of the incident?
2) Did the incident occur outside the United States?
If you answered NO to either of these questions, you are not eligible for ITVERP and should
not complete this application. If you answered YES to both of these questions, please
complete the application. Be aware, the application requires a considerable amount of detail
and may take a significant amount of time to complete.
GENERAL INSTRUCTIONS
Please type or print clearly and do not use any correction fluid on this application. Attach
additional supplemental sheets as needed for each expense category. If you have questions
or would like assistance in completing this application, contact an ITVERP case manager by
phone at 1–800–363–0441 or by email at itverp@ojp.usdoj.gov. Please be sure to include
all supporting documentation with your application.
Note: ITVERP does not cover attorney's fees, lost wages, or noneconomic losses, such as
pain and suffering, loss of enjoyment of life, etc.
A. APPLICATION TYPE
The type of application you submit depends on the kind of reimbursement you are requesting.
Each type of application requires specific information. Please review the application options
below to determine which type of application is appropriate for your situation. Choose only
one.
□
Itemized
□
Supplemental
□
Interim Emergency
Application Application Application (Conditional)
This is the most common This is for ITVERP claimants
This is for immediate financial
ITVERP application. If this who have a prior ITVERP
hardship only. If you check this
is your first time filing an application and are now
box, you must describe the
ITVERP claim, and you submitting additional
reason for your substantial
are not asserting a expenses for reimbursement.
financial hardship. This type of
substantial financial Please include your previous
application is limited to: medical
hardship, please check claim number here:
care, funeral and burial costs,
this box. ______________________
short-term lodging, and
emergency transportation.
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
1
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
For Interim Emergency Applicants Only: Please provide a detailed statement below about
the substantial financial hardship you will incur if your ITVERP application is not processed as
an Interim Emergency Application. (Attach additional paper if necessary.)
B. REQUEST FOR EXTENSION OF FILING DEADLINE
Generally, the filing deadline for an ITVERP claim is 3 years from the date of the international
terrorist incident; however, ITVERP regulations allow the Director discretion to waive this
deadline upon a showing of good cause. If you are a new claimant and are submitting this
application more than 3 years after the date of the incident, you must state the reason you
missed the program’s filing deadline.
Are you filing the application within 3 years of the date of the terrorist incident?
Yes No (If you checked “no,” please complete the information below.)
C. CLAIMANT AND VICTIM INFORMATION
There is only one ITVERP claim per victim. The victim is the person who was injured or killed
as a result of the incident and is often also the claimant for the purpose of submitting an
application. Sometimes the claimant is not the direct victim, but rather a surviving family
member or representative of the victim who submits the application on behalf of the victim.
The only exception to the one claim per victim rule is when the victim is deceased and
surviving family members apply for mental health expense reimbursement. In those cases,
each family member would file their own claim for mental health reimbursement.
What is your relationship to the victim?
Self Spouse Child Parent Sibling Other ________________________
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
2
REQUIRED DOCUMENTS
Please include all of the information requested below.
Victim Identification: A copy of a valid, government-issued photo ID.
Certificate of Death: If the victim is deceased, a copy of a death certificate or other official
recognition of death.
Claimant Identification: A copy of a valid, government-issued photo ID.
Claimant & Victim Relationship Verification: A copy of a legal document substantiating the
relationship between the victim and claimant, such as a marriage certificate, birth
certificate, power of attorney, will, health care directive, etc.
CLAIMANT INFORMATION:
The claimant is the person other than the victim who is completing the application. If you are the
victim, please skip this section and go to the Victim Information section below.
Claimant First Name Claimant Last Name Middle Initial Date of Birth
Street Address City State Zip Code
Country of Citizenship Telephone
Gender
□ Male
□
Female
Email
Social Security Number/Employee Identification Number/Other Identification Number (Please identify the type of
number used.)
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
3
VICTIM INFORMATION:
All ITVERP applications must include complete information about the victim. If you are
the claimant, you must complete this section.
Victim First Name Victim Last Name Middle Initial Date of Birth Place of Birth
Street Address City State/Country Zip Code
Country of Citizenship Telephone
Gender
□ Male
□
Female
Email
Social Security Number/Employee Identification Number/Other Identification Number (Please identify the type of
number used.)
Is the victim a veteran?
□
Yes
□
No
Victim’s Employer
(If victim was working abroad
or for the U.S. Government.)
Victim’s Employer’s Address
Victim’s Supervisor/Contact Person – Name (if
known)
Victim’s Supervisor/Contact Person – Email and Phone (if
known)
D. INTERNATIONAL INCIDENT INFORMATION
The incident must have occurred outside the United States.
Date of Incident Location of Incident (City, Country) Lead Investigative Agency
Brief Description of Incident
Brief Description of Injuries
REQUIRED DOCUMENTS
Please include any and all supporting documents related to the incident, such as a police
report, news articles, photographs, etc.
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
4
E. OUT-OF-POCKET EXPENSE INFORMATION
Please read the following information carefully as it may impact your reimbursement request.
If you have any questions, please contact us.
1. Collateral Sources: ITVERP is a payer of last resort. This means that ITVERP will only
provide reimbursement for out-of-pocket expenses that are
not
covered by some other
source, like an employer or insurance company. ITVERP will contact all other potential
collateral sources to verify whether they covered the expense (in whole or in part) for which
you are requesting reimbursement.
2. Service Providers: ITVERP will contact relevant service providers to verify receipt of
services, the cost incurred, and if the service(s) were linked to the incident. If the services
were not linked to the incident, the reimbursement request for that expense will be denied.
3.
Third Party Contributions: If you are submitting expenses that another person(s) may have
contributed to paying, such as family members or friends, these expenses are considered
out-of-pocket expenses incurred by a third party. ITVERP regulations require that each
claimant (the person filing the application) obtain approval from the people who
contributed to paying those expenses in order for ITVERP to reimburse the claimant on
behalf of those third parties.
4. Currency Type: Please state all payment amounts in the same currency in which the out-
of-pocket expense was incurred.
REQUIRED DOCUMENTS
In the appropriate expense categories, you must include as much detail as possible
(with supporting documentation) in order for ITVERP to contact your service providers. When
possible, you must submit copies of original receipts and copies of any documentation that
you have to help substantiate your expenses.
F. MEDICAL EXPENSES
Are you requesting reimbursement for out-of-pocket medical expenses?
Go to the Mental Health Expense section.
Yes
No
What is the total out-of-pocket expense in this category? _____________________
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
5
Go to the Service Provider section below.
Have any other sources or person(s) covered these medical expenses?
No
Yes Complete the chart below for each medical expense.
Applicable sources of coverage (or financial assistance) for each expense could include
private, group, employer, or union health insurance providers; veteran’s and military benefits;
workers' compensation; proceeds from civil litigation; state compensation; FBI emergency
assistance; Medicare, SSI, and SSDI.
You must attach copies of supporting documentation for each expense.
Medical Expense Please list each medical expense for which you are seeking reimbursement.
Describe the Medical Expense What was the out-of-pocket cost?
(If not in U.S. Dollars [USD], please
identify the currency.)
Date Medical Expense was Incurred
Name of Service Provider Contact Person’s Name Email Telephone
Provider’s Address City State Zip Code
Medical Coverage Please identify all sources of financial assistance for each expense, including
family members or friends who may have covered your expenses.
Coverage Source’s Name Policy # – Acct # – Claim # Contact Person’s Name
Coverage Source’s Address Source’s Telephone Source’s Email/Fax
For additional expenses, please refer to Supplemental Sheet F: MEDICAL EXPENSES.
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
6
G. MENTAL HEALTH EXPENSES
Are you requesting reimbursement for out-of-pocket mental health expenses?
No Go to the Property Loss Expense section.
Yes What is the total out-of-pocket expense in this category? _____________________
Have any other sources or person(s) covered these mental health expenses?
No G Go to
the Service Provider
section below.
Yes Complete the chart below for each mental health expense.
Applicable sources of coverage (or financial assistance) for each expense could include
private, group, employer, or union health insurance providers; veteran’s and military
benefits; workers' compensation; proceeds from civil litigation; state compensation; FBI
emergency assistance; Medicare, SSI, and SSDI.
You must attach copies of supporting documentation for each expense.
Mental Health Expense Please list each mental health expense for which you are seeking reimbursement.
Describe the Mental Health
Expense
What was the out-of-pocket cost?
(If not in USD, please identify the
currency.)
Date Mental Health Expense was Incurred
Name of Service Provider Contact Person’s Name Email Telephone
Provider’s Address City State Zip Code
Mental Health Coverage Please identify all sources of financial assistance for each expense,
including family members or friends who may have covered your expenses.
Coverage Source’s Name
Policy # – Acct # – Claim # Contact Person’s Name
Coverage Source’s Address
Source’s Telephone
Source’s Email/Fax
For additional expenses, please refer to Supplemental Sheet G: MENTAL HEALTH EXPENSES.
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
7
H. PROPERTY LOSS EXPENSES
Are you requesting reimbursement for out-of-pocket property loss expenses?
No Go to the Funeral and Burial Expense section.
Yes What is the total out-of-pocket expense in this category?__________________
Required Supporting Documentation: For property loss, you must provide supporting
documentation of the cost you incurred, such as copies of receipts, photographs, credit card
statements, or other documentation that shows the cost of the property at the time it was
purchased.
Detailed Itemized List: If you do not have any documentation to support your property loss
claim, you must submit an itemized statement with specific details about the item and
attest, under penalty of perjury, that the information provided is true and correct to the best
of your knowledge. Itemized lists without specific details will not be accepted for property
loss verification.
Please list a detailed description of your specific items below.
Item
Name
Detailed Description
Cost at
Time of
Purchase
(if not in USD,
please identify
the currency)
Was the
Item
Insured?
Attached
Supporting
Documentation
Example:
Digital
Camera
1 Canon PowerShot S95 Camera
with 10 megapixels, 4x zoom, 3”
LCD display and SD memory card
slot
988 AED
No Receipt
1.
2.
3.
You must attach copies of supporting documentation for each expense. For additional
items, please refer to Supplemental Sheet H: PROPERTY LOSS.
CERTIFICATION
I certify that the information provided on this itemized list of property loss (and the attached
Supplemental Sheet H: Property Loss) is true and correct to the best of my knowledge.
Signature: ____________________________________ Date: _______________________
Claimant’s Signature
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
8
I. FUNERAL AND BURIAL EXPENSES
Are you requesting reimbursement for out-of-pocket funeral and/or burial expenses?
No
Go to the Miscellaneous Expense section.
What is the total out-of-pocket expense in this category? ___________________
You
must
attach
copies
of
supporting
documentation for each expense.
Yes
Please list a detailed description of your requested expenses below.
Type of
Expense
Detailed
Description
Total Cost at
Time of
Purchase
(If not
in USD, please
identify the currency)
Amount
Covered by
Other
Sources
Purpose of
Expense
Attached
Supporting
Documentation
Example:
Airfare
Roundtrip airline
ticket—San Diego,
CA, to Fort Knox,
TN, for John Smith
$498.00 0 Attending
induction
ceremony
Bank statement
1.
2.
3.
Third Party Contributions: Has any other person(s), such as a family member or friend, paid for
part of the out-of-pocket funeral and/or burial expenses for which you are seeking
reimbursement?
No Go to the Miscellaneous Expense section.
Yes Complete the chart below.
Person(s) Who
Paid
Contact Information for
Person(s) Who Paid
Relationship
Amount Paid (If
not in USD, please
identify the currency.)
For What
Expense
Name
Address, email, and telephone
Name
Address, email, and telephone
For additional items, please refer to Supplemental Sheet I: FUNERAL & BURIAL.
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
9
J. MISCELLANEOUS EXPENSES
Are you requesting reimbursement for out-of-pocket miscellaneous expenses?
No
Go to page 11.
What is your total out-of-pocket expense in this category? ____________________
You must
attach copies
of
supporting
documentation for each expense.
Yes
Please list your specific expenses below.
Type of
Expense
Detailed
Description
Cost at Time
Expense was
Incurred
(If not
USD, please identify
the currency.)
Amount
Covered by
Other
Sources
Purpose of
Expense
Attached
Supporting
Documentation
Example:
Phone
charges from
Mumbai,
India, to
Oakland, CA
Incurred expense
while in Mumbai
attending to victim’s
affairs, June 2004
$384.28 No Putting victim’s
affairs in order
Phone bill
Third Party Contributions: Has any other person(s), such as a family member or friend, paid
for part of the out-of-pocket miscellaneous expenses for which you are seeking reimbursement?
No Proceed to page 11.
Yes Complete the chart below.
Person(s) Who
Paid
Contact Information for
Person(s) Who Paid
Relationship
Amount Paid
(If
not in USD, please
identify the currency.)
For What
Expense
Name
Address, email, telephone
Name
Address, email, telephone:
For additional items, please refer to Supplemental Sheet J: MISCELLANEOUS.
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
10
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Instructions: Please read each statement below. Your signature at the bottom indicates your
agreement with the terms of the program and certification that all statements and information
provided in this application are true and correct to the best of your knowledge.
K. CONSENT AND CERTIFICATION
This release must be signed and dated before your application can be considered for expense reimbursement.
I hereby agree to contact and repay ITVERP if I receive any payments from the person or
governments responsible for the act of international terrorism, a civil lawsuit, an insurance
policy, a debt waiver, or any other government or private agency to cover expenses for which I
have already received payment from this program.
Any unsatisfied judgment against a foreign government will be considered a collateral source
of financial help, and your ITVERP reimbursement will be reduced accordingly, unless you
agree to NOT sue the United States Government for satisfaction of that judgment by signing
and dating the following:
I waive any right I may have to sue the United States Government for satisfaction and
enforcement of my unsatisfied judgment against the foreign government for the act of terrorism
for which I am claiming reimbursement from ITVERP.
I hereby certify, subject to penalty of fine or imprisonment or both, that below I have listed all
names and addresses of all other individuals who may be eligible to receive expense
reimbursement in relation to the victim in this claim.
I hereby certify, subject to penalty of fine or imprisonment or both, that I am neither directly nor
indirectly responsible for the incident for which I am seeking expense reimbursement.
I hereby certify, subject to penalty of fine or imprisonment or both, that the information
contained in this application for the International Terrorism Victim Expense Reimbursement
Program (ITVERP) is true and correct to the best of my knowledge.
Victim/Claimant Signature Date
Representative’s Signature
(or signature of individual Date
who assisted in the preparation of this application)
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
11
_____________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
AUTHORIZATION FOR USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION (HIPAA Compliance)
This release must be signed and dated before your application can be considered for expense reimbursement.
I hereby authorize my health care provider to disclose my protected health information, described
below, to ITVERP. You may disclose this information to: ITVERP Resource Center, Office for Victims of
Crime, 810 Seventh Street NW, Washington DC, 20531; or by email: itverp@usdoj.gov.
I hereby authorize any physicians, clinics, psychologists, dentists, chiropractors, nursing homes,
pharmacies, acupuncturists, or naturopaths to furnish ITVERP program representatives with any
information requested, including medical records, diagnostic assessments, and mental health
evaluations, needed to complete my claim for expense reimbursement. A photocopy of this
authorization shall be considered as effective and valid as the original.
I hereby authorize any health insurance companies, HMOs, employer health plans, and government
programs—such as Medicare, Medicaid, and military and veterans’ health care programs—to furnish to
ITVERP program representatives with any information requested, including medical records, diagnostic
assessments, and mental health evaluations, needed to complete my claim for expense
reimbursement. A photocopy of this authorization shall be considered as effective and valid as the
original.
I hereby authorize a funeral director; municipal authority; employer or union; insurance company; social
service bureau; Social Security office; or any other person, firm, agency, or organization to furnish
ITVERP program representatives with any information requested to complete my claim for expense
reimbursement. A photocopy of this authorization shall be considered as effective and valid as the
original.
This authorization expires when ITVERP completes verification of my claimed expenses.
Revocation: I understand that if I revoke this authorization, the ITVERP expense verification process
cannot be completed. I understand that to revoke this authorization I must submit a written letter to
ITVERP stating authorization is revoked, or I may contact the ITVERP program representative and
verbally revoke authorization. I understand revocation is only effective after it is received and recorded
by ITVERP. Any use or disclosure made prior to revocation will not be affected as part of this
revocation.
Victim/Claimant Printed Name Date
Victim/Claimant Signature Date
Representative’s Printed Name Date
Representative’s Signature (or signature of individual Date
who assisted in the preparation of this application)
For assistance contact:
810 Seventh Street, NW • Washington, DC 20531 • 1–800–363–0441 • ITVERP@usdoj.gov
www.ovc.gov
12
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ITVERP Application International Terrorism Victim Expense Reimbursement Program (ITVERP) Application

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Completed 8 February 2020

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