EFTA01650976.pdf

• Federal Bureau of Investigation Victim Services Division Epstein Briefing RSVP October 15, 2019 - Miami, FL I I October 23, 2019 - New York, NY Please fill out the following form and return to the VictimServices@fbi.gov emailbox by October 4, 2019. Full Name: Email Address: Phone Numbe r: Social Security Number: Address 1: Address 2: City: State: Zip: Date of Birth: Citizenship: Country of Birth: If you have spoken with a FBI Victim Specialist, please provide their name: Can you attend? • Yes, I will attend ❑ No, I cannot attend If yes, which location will you attend? 10/15/2019 Miami, Fl 0 10/23/2019 New York, NY You are authorized to bring one support person. Will you be bringing a support person with you to the briefing? • Yes, I will bring one support person No, I will not bring a support person Will you need travel arrangements? • Yes, I will need travel arrangements E No, I will not need travel arrangements If yes, which mode of transportation do you prefer? Air E Rail Bus E Mileage reimbursement (if you are utilizing your own vehicle) Only economy, roundtrip fares and one checked luggage bag per person will be authorized. You will be responsible for any incidental charges incurred such as in-flight snacks, Pay-Per-View, Wi-Fi, etc. Airport of origin: Preferred time of travel: Do you require lodging? Only two nights of lodging will be authorized and only hotel room cost and tax will be authorized. You will be required to provide a credit card for incidental charges upon check in. You will be responsible for any incidental charges incurred such as snacks, mini bar, Pay-Per-View, phone charges, etc. Yes, I will require lodging 0 No, I will not require lodging Do you require airport transportation? Yes, I will require transportation to/from the airport No, I will not require transportation to/from the airport EFTA01650976 Support person information Support Person's Name: Relationship: Email Address: Phone Number: Social Security Number: Address 1: Address 2: City: State: Zip: Date of Birth: Citizenship: Count'', of Birth: Will your support person need travel arrangements? Yes, my support person will need travel arrangements J No, my support person will not need travel arrangements If yes, which mode of transportation do they prefer? Air Rail _ Bus _ Mileage reimbursement (if they are utilizing their own vehicle) Only economy, roundtrip fares and one checked luggage bag per person will be authorized. You will be responsible for any incidental charges incurred such as in-flight snacks, Pay-Per-View, Wi-Fi, etc. Airport of origin: Preferred time of travel: If bringing a support person, will your support person require separate lodging? Only two nights of lodging will be authorized and only hotel room cost and tax will be authorized. You will be required to provide a credit card for incidental charges upon check in. You will be responsible for any incidental charges incurred such as snacks, mini bar, Pay-Per-View, phone charges, etc. Yes, my support person will require separate lodging No, my support person will not require separate lodging If bringing a support person, will your support person require airport transportation? Yes, my support person will require transportation to/from the airport No, my support person will not require transportation to/from the airport Acknowledgement and Signature By checking and signing below, I acknowledge I have read and understand that only lodging, lodging taxes, mileage, and commercial transportation expenses (airfare, bus, train, and hotel transportation only) will be authorized as outlined above. I understand that the following will not be included/provided in the authorized expenses: meals, rental vehicle, entertainment, or other incidental charges. Yes, I acknowledge Signature Date: the above statement 2 EFTA01650977