Objection/statement Of Interest Form (Page 3 of 5) in pdf

Objection/statement Of Interest Form Page 3

OMB Number 1105-0077

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

with

the Victim Compensation Fund.

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

Objection/statement Of Interest Form Page 3