I am a U.S. citizen *

Yes

No

Family member(s) are U.S. citizen(s) *

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 victim of a terrorist attack *

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)

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Terrorist Organization Perpetrator (if known)

Taliban

Al- Qaeda

Hizballah

Haqqani Network

HAMAS

Palestinian Islamic Jihad

AL-Aqsa Martyrs Brigade

Popular Front for the Liberation of Palestine

Fatah Tanzim

Other

Type of Attack *

EFP

IED

IBED

Rocket

Mortar

Suicide Bomb

RPG

Small Arms

Other