EFTA00155074.pdf

Merson Law, PLLC Merson Law, PLLC LIAM WtAv.Mersonbw,com Please mal all correspondence to Woffice February 15, 2024 VIA PERSONAL SERVICE Federal Bureau of Investigation Federal Bureau of 935 Pennsylvania Avenue, NW Investigation 26 Federal Plaza, Washi o D.C. 20535 23rd Floor York 10278 Re: Service of Standard Form 95 Dear Ma'am/Sir: Enclosed for service, please find a signed Standard Form 95 for Claimant M, who is represented by my office. If you have any questions, please feel free to contact me at your convenience. Thank you for your time and attention to this matter. Very truly yours, '' sacra\fS °1 Jordan Merson Ijm encl: EFTA00155074  CLAIM FOR DAMAGE, INSTRUCTIONS: Neese read carefully the instructions on the FORM APPROVED reverse side and supply Information requested on both sides of thb OMB NO. 1105-0008 INJURY, OR DEATH fon. Use eddrilonal sheet(s) if neoessary. See flIverse side for additional instructions. 1. Submit to Apse/prate Federal Agency: 2. Name, address of claimant. and cblmanTs personal ropresentatEo t any. See instr-cobra on reverse). Number, Sheet. OW. Stale and zip cede. Federal Bureau of Investigation, J. Edgar Hoover Building, 935 Pennsylvania Avenue, NW, Washington, D.C. 20535 c/o Merson Law, PLLC, 3. TYPE OF EMPLOYMENT 4. DATE OF BIRTH 6. MAR/TAL STATUS O. DATE MIDDAY OF ACQDENT 7. TIME (AM. OR PM.) • Lamar FIcwitim 2004-2006 Various/Multiple 8. BASIS OF CLAIM (Ste's In detail the known fads end circu damage. Injury. or death. Identifying persons and property Invohed, the place the cause thereof. Use additnnal pages If necessary). of °cairn/nos end This claim arises out of the sexual abuse suffered by Claimant Claimant") at the hands of Jeffrey Epstein ("Epstein") as a result of the gross neglig acts, and/or omissions of the Federal Bureau of Investigation ("FBI"). Specifically, despite the fact that in 1996, reported to the FBI that she had been sexually abused by Epstein, reports from the Palm Beach Police In 2005-2006 and despite having other notice of Epstein's sexual abuse of women and children, nothing was done, and Epstein proceeded to sexually abuse countless other women and children, including Claimant, until he was arrested on July 6, 2019. 9. PROPERTY DAMAGE NAME AND ADDRESS OF OWNER, IF OTHER 'NAN CLAIMAhT (Number. Street OW,ELS, and Zip Code). ... None. BRIEFLY DESCRIBE THE PROPERTY. NATURE AND E<TENT OF THE DAMAGE MOVE LOCATION OF WHERE 714 PROPERTY MAY (See 'nstfuceons on reverse aide). BE INSPECTED. None. 10. PERSONAL /NJURYAWIONGFUL DEATH STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF MATE WHICH FORMS THE BASIS OF THE CLAIM. F OTHER THAN CLAIMANT. STATE TIE NAME OF TIE INJURED PERSON Oft DECEDENT. As a result of being repeatedly sexually abused by Epstein, Claimant was caused to suffer severe emotional and physical pain and suffering, post-traumatic stress disorder, insomnia, anxiety, shock, fear, nightmares, shame, embarrassment, loss of enjoyment of life, flashbacks, need for future medical and psychiatric expenses, and other severe injuries. 11. WITNESSES NA/AE ADDRESS (Number. Seel C4 Stele. and Zip Code) 12. (See Instructions on reverse). AMOUNT OF CLAIM On donor') 12a. PROPERTY DAMAGE 12b. PERSONAL INJURY 12s WRONGFUL DEATH 12d. TOTAL (Falure lo specify mays:has brfarme of your rights). 20,000,000 20,000,000 I carry THAT THE AMOU CLAIM COVERS ONLY DAMAGES AND IIIJURJES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN FULL SATISFACTION AND FINAL INTO SETTLEJAENT OF TNS CLARA 1Se.S/GNATURE OF MAIMANT (See Instructons on reverse side). 134. PHONE NUMBER OF PERSON SIGNING FORM 14. DATE OF SIGNATURE I Iftt/k 02/09/2024 an. PENALTY FOR PRESEKUNG CRAREAL PENALTY FOR PRESENTING FRAUDULENT . FRAUDULENT CLAIM CLAIM OR MAKING FALSE STATEMENTS The deknant Ls gable to the (Inked Sates Government for a OrrS penally of not :oss than Fine, Imprisonment of both. (Sae 18 U.S.C. 287. 100t.) 55,000 and not more than $10.000, plus 3 limos the amount of damages mrstened by the Government (See 31 V.S.C. 37293 Authorized for Local Reproduction NSN 7540-00434-4DM STANDARD FORM 95 (NEV. 212007) Previous Edition Is not Usable PRESCRIBED BY DEPT. OF JUSTICE 9S-109 28 CFR 14.2 EFTA00155075  INSURANCE COVERAGE In order that unawake chants may bo adjudtated, it Is essential that the deepest provide the following Mk/lotto regarding the insurance overage Mlle vehkie a property. 15. Do you cony Occident Insurance? O Yes Ilya:, gito name and addross of insurance company (Number, Street, City. Stalk and 21p Code) and policy punter. JET No none. 16. Rao you lied a dam with your Insurance carrier et Nis Instance, and t SO, b it full coverage or doCucgtdo? O Yes 2Nd ILI( deductible, shAe arnounL none. 0.00 18. If a dalm has been Ned with your terrier, what adder has yes biota (Moo s proposed to lake wth reference to our clam? (It ls noosing that you meth* theft leas). none. 19. Do you cony public lief:airy and property damage ignorance? O Yee If yes. give name end address of Insurance corder (Nnneer. Soot, City. Slate. are Zip Cede). No none. INSTRUCTIONS Claims presented tinder the Federal Tort Claims Act should be submitted directly to the "appropriate Federal agency" whose employee(s) was involved in the incident. N the incident involves more than ono claimant, each claimant should submit a separate claim form. Complete all Items -Insert the word NONE whore appli cable. A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL DAMAGES IN A EUMDERIAIN FOR LNJURY TO OR LOSS OF PROPERTY. AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR LEGAL PERSONAL INJURY. OR DEATH ALLEGED TO HAVE OCCUFtRED BY REASON OF TIE INCIDENT. REPRESENTATIVE. AN EXECUTED STANDARD FORM 9508 OTHER WRITTEN THE CLAIM MUST BE PRF_SEVTEG TO THE APPROPRIATE FEDERAL AGENCY NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR MONEY WITHIN DVILYEARE AFTER THE CLAIM ACCRUES. Failure to completely execute Ns form or to supply the requested material within The amount chained should be substantiated by competent evidence as fdlows: two years from the date the claim accrued may render your claim Invalid. A claim is deemed presented when It Is received by the appropriate agency, not when it is (a) In support el the o aim for personal .injury or death. the claimant should subiat a written report by the attending physician. showing the nature and extent of the Injury, the nature and extent of treatrnord, the degree of permanent disability, d any, the etcrOesIS, and the period of hosprolization, or incepsolOon, attaching :embed bins for moecal, if trotnictIon is needed In completing Ins form. the regency Hated In Hem et on the reverse hospital, or burial expenses actually Incurred. sloe may be oonMeted. Compote regtkatens perternine to claims assorted under the Fedora Tort Claims Act can be found In Tide 28, Code ol Federal Regulators, Pant 4. Many ;goon have published supplementing osculations. II more than. era agency Is (b) In support of claims to damage to property, which has been or can be ecenctr d y InvoNed, please state each Oen* repaired, the Clamant should submit at least two Nornized signed statements or estimates by reilatle, disinterested cocoa oil payment has been made, the Oinked signed receipts evidencing payment. The cake may be Bled by a tidy authorized agent or other legal representative, provided evidence sedsfaday to the Government Is submitted with the dant eslabTshinis express allforhs to act for the c'aimant. A claim presented by an agent or legal representative (a) In supped of claim los damage lo property Mittel Is Mat economically repairable. roust to presented into name of the oblrnant. rf the claim is signed by the agents or If the property Is Sod or destroyed, uric element should submit SlAtormans as to the original legal urpreaornaiNts, it must show the tale or legal cooly of the person signing and be Coat of the property, the date of purchase, and the value of the property, both before and ascot-oar:rad by evidence delirium authority to mon( a claim cn behalf of the claimant after the sodden Such statements should be by onieterer,ted competent persons ea agent executor. acknInktraler, parent. guaroian or other representative. Preferebty reputable dealore pr ofliciaa tangier with the type of property damaged. or by two or more corpeithe bidders, and should be coifed ax being just and correct If clamant Intends to the for both personal injury end property damage, the smont for coon mint be anon Si kern number 12 of this firm. (r0 Failure to specify a sum certain ON render your claim Invalid and may result In redskin* of your rights. PRIVACY ACT NOTICE Thls Notice le provided Si accordance with the PrivacyAd. 5 U.S.C. 552e(e)(3). and B. Prtriolsal Purpose: The InIcanaCon requested is to be used In evaluating dame COTO"' the Inforrotho requested In the letter to which this Notice Is attached. C. Rouen. Use: See Be Nodoseel Syclems of Records for the agency to warn you A. Authority: The requested informalka Is solicited pursuant to one or Mem alto ere manning this ram for this Informs:ion. blowing: 5 U.S.C. 301, 28 U.S.C. 501 el seq.. 28 U.S.C. 2871 et Seq.. 28 C.F.R. 0. Effect of Failure JO Rospord: Disdosum IS voluntary. However. Dilute to supey the Port 14. requested keertnallon or to execute the Ion may render yoLr claim 'Snead? PAPERWORK REDUCTION ACT NOTICE This mace Is aataly for the purpose tithe Panora* Reduction Act, 44 U.S.C. 3501. Pubk reporting burden for trio collo-Eon of Information Is esliearred to average a hours per response. Mclud Loathe Dee for coloring Instructions. searching exklIng data sources, gathering and maintaining the data Inn-Amapa Send comments regarding Ulla burden alienate or any crier aspect of this cello: flooded and completing and reviewing the oliectien of don of Inl0fMadon, kneudIng suggestions for reducing this burden, to the Director. TOM Eh arch, Mention: Paperwork Reduction Stall. COO ()Makin. U.S. Department °T./ask., Washington, DC 20530 a to the Cat of Management and Budget Do not mar cornea:kid tam(c)In :Mai adtalatt. STANDARD FORM 95 REV. (2/2007) BACK EFTA00155076  Final SF95-07a Final Audit Report 2024-02-09 It Final SF95-07a" History e Document created by Kamelle Detin 2024-02-09 - 8:06:13 PM GMT- IP address: a Document emailed to for signature 2024-02-09 - 6:06:18 PM GMT IB Email viewed by 2024-02-09 • 6:19:21 PM GMT- II' addres 43 Document e-signed by • Signature Date: 2024-02-09 - 6:22:57 PM GMT - Time Source: server- IP address: el Agreement completed. 2024-02.09 - 6:22:57 PM GMT is Adobe Acrobat Sign 41•13. 23:~1,1:179 ICTIO=.11. J7ZI:Calia• W.GateltaMtir EFTA00155077