Objection/statement Of Interest Form (Page 2 of 5) in pdf

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

1900 K Street, NW Suite 900

Washington, DC 20036-8698

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

Objection/statement Of Interest Form Page 2

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