REQUEST FOR CONFIDENTIAL, FREE EVALUATION OF POTENTIAL CLAIM Please check all of the following that apply: I am a U.S. citizen * Yes No Family member(s) are U.S. citizen(s) * Yes No At the time of the terrorist attack, I was an employee of the U.S. government (“USG”) * U.S. Embassy/State Department/USAID Department of Defense/U.S. Army/Navy/Air Force/Marines Department of Justice/FBI Treasury Department Homeland Security Other At the time of the terrorist attack, I was employed by a contractor of USG Yes No I received an award/citation/certificate for my actions during/after the attack Yes No I have a disability rating Yes No I was present within the “zone of danger” during the terrorist attack Yes No I was physically injured in the terrorist attack. Yes No I am a family member of an injured or killed employee or contractor of USG Yes No My family member was injured in or as a result of the terrorist attack. Spouse (life partner) Child (including stepchild, adopted child, informally adopted child): Parent (including stepparent) Sibling (including half sibling) My family member was killed in or as a result of the terrorist attack Spouse (life partner) Child (including stepchild, adopted child, informally adopted child): Parent (including stepparent) Sibling (including half sibling) My Family Name First Name Middle Names Email Phone (###) ### #### Date of Birt MM DD YYYY If you are a family member of the victim/survivor of the terrorist attack, please answer the following: If you are a family member of the victim/survivor of the terrorist attack, please answer the following: Family Name of the victim/survivor First name of the victim/survivor Middle names of the victim/survivor Convenient days of the week & times to call you Date of the Attack Location: City/FOB Province Terrorist Organization Perpetrator (if known) Taliban AL-Qaeda Haqqani Network ISIS Hizb-e- Islami Gulbuddin (HIG) Islamic Movement of Uzbekistan (IMU) Tehrik-i-Taliban Pakistan (TTP) Hizballah HAMAS Palestinian Islamic Jihad Kata'ib Hizballah Jyash al-Mehdi Asa'ib Ahl al-Haq IRGC IRGC Quds Force Other Details of Attack – (what happened to you?) If you are a family member of the victim/survivor, please describe briefly details of the attack, Names and emails of other family members or friends who may have claims: List names and relationship Thank you!
