Fillable International Terrorism Victim Expense Reimbursement Program (ITVERP) Application Supplemental Sheets (U.S. Department of Justice)

Fill Online, Printable, Fillable, Blank International Terrorism Victim Expense Reimbursement Program (ITVERP) Application Supplemental Sheets (U.S. Department of Justice) Form

Use Fill to complete blank online U.S. DEPARTMENT OF JUSTICE (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

International Terrorism Victim Expense Reimbursement Program (ITVERP) Application Supplemental Sheets (U.S. Department of Justice)

On average this form takes 50 minutes to complete

The International Terrorism Victim Expense Reimbursement Program (ITVERP) Application Supplemental Sheets (U.S. Department of Justice) form is 5 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 200 other fields

Country of origin: US
File type: PDF

U.S.A. forms for U.S. Department of Justice

BROWSE U.S. DEPARTMENT OF JUSTICE (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
U.S. Department of Justice
OMB Number 1121-0309
Expiration: 3/31/2021
Office of Justice Programs
Office for Victims of Crime
Supplemental Sheet F: MEDICAL EXPENSES
If necessary, please attach additional sheets using this format.
Medical Expense
Please list each medical expense for which you are seeking reimbursement.
Describe the Medical Expense:
What Was the Out-of-Pocket Cost?
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:
Medical Expense
Please list each medical expense for which you are seeking reimbursement.
Describe the Medical Expense:
What Was the Out-of-Pocket Cost?
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:
Please attach supporting documentation for each expense, such as insurance statements,
invoices, copies of receipts, credit card statements, Explanation of Benefits, etc.
For assistance call 1-800-363-0441 or email itverp@ojp.usdoj.gov
Supplemental Sheet G: MENTAL HEALTH EXPENSES
If necessary, please attach additional sheets using this format.
Mental Health Expense
Please list each mental health expense for which you are seeking reimbursement.
Describe the Medical Expense:
What Was the Out-of-Pocket Cost?
Date Medical 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:
Mental Health Expense
Please list each mental health expense for which you are seeking reimbursement.
Describe the Medical Expense
What Was the Out of Pocket Cost?
Date Medical 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:
Please attach supporting documentation for each expense such as insurance statements,
invoices, copies of receipts, credit card statements, Explanation of Benefits, etc.
For assistance call 1-800-363-0441 or email itverp@ojp.usdoj.gov
Supplemental Sheet H: PROPERTY LOSS EXPENSES
If necessary, please attach additional sheets using this format.
Please list in detail, your specific items below.
Item Name
Detailed Description
Cost at
Time of
Purchase
item
Attached
Supporting
Documentation
Example:
Digital Camera
1 Canon PowerShot S95 Camera
with 10 megapixels, 4x zoom, 3”
LCD display and SD memory card
slot.
$865.00
No Receipt
Please attach supporting documentation for each expense such as copies of receipts, credit
card statements, pictures of the items, etc.
For assistance call 1-800-363-0441 or email itverp@ojp.usdoj.gov
Supplemental Sheet I: FUNERAL & BURIAL EXPENSES
If necessary, please attach additional sheets using this format.
Please list in detail, your requested expenses below.
Type of
Expense
Detailed
Description
Total Cost at
Time of
Purchase
Amount
Covered by
Other Sources
Purpose of
Expense
Attached Supporting
Documentation
For each expense you must attach copies of supporting documentation.
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?
If so, complete the chart below.
Person(s) Who Paid
Contact Information for
Person(s) Who Paid
Relationship Between
Claimant and Who Paid
Amount
Paid
For What
Expense
Name:
Address, email, and telephone:
Name:
Address, email, and telephone:
Name:
Address, email, and telephone:
Please attach supporting documentation for each expense such as copies of receipts, credit
card statements, etc.
For assistance call 1-800-363-0441 or email itverp@ojp.usdoj.gov
Supplemental Sheet J: MISCELLANEOUS EXPENSES
If necessary, please attach additional sheets using this format.
Please list your specific expenses below.
Type of
Expense
Detailed
Description
Cost at Time
Expense Was
Incurred
Amount
Covered by
Other Sources
Purpose of
Expense
Attached
Supporting
Documentation
Example:
Phone bill
Phone charges
from India to
Knoxville, TN while
in India attending to
victim’s affairs –
June/July 2004
$384.28USD No Putting victim’s
affairs in order
Phone bill
For each expense you must attach copies of supporting documentation.
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?
If so, complete the chart below.
Person Who Paid
Contact Information for
Person(s) Who Paid
Relationship Between
Claimant and Who P
aid
Amount
Paid
For What
Expense
Name
Address, email and telephone
Name
Address, email and telephone
For assistance call 1-800-363-0441 or email itverp@ojp.usdoj.gov
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

International Terrorism Victim Expense Reimbursement Program (ITVERP) Application Supplemental Sheets (U.S. Department of Justice)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document