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

OMB Number 1105-0077

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 11

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

Objection/statement Of Interest Form Page 5