Name * First Name Last Name Email * Phone * (###) ### #### Claim for Evaluation Choose October 7 Atrocities US Embassy Bombing Human Trafficking/Slavery Other Citizenship US Other Citizenship of Victim/Survivor of the Attack US Citizen Other Please check the one that applies: I was injured (physically or emotionally) in or as a result of the terrorist attack. My family member was injured in or as a result of the terrorist attack My family member was killed in the terrorist attack. If a family member was affected, indicate relationship: Spouse (life partner) Child (including stepchild, adopted child, or informally adopted child) Parent Sibling (including half-sibling) Date of Attack: Location: Terrorist Organization/Perpetrator (if known): Details of Attack (what happened to you): If you are a family member of the victim/survivor, briefly describe details of the attack: Other Family Members Who May Have Claims List names and the relationship Thank you!
