| CLAIM FOR DAMAGE, INJURY, OR DEATH | INSTRUCTIONS: Please read carefully the instructions on the reverse side and supply information requested on both sides of this form. Use additional sheets if necessary. See reverse side for additional instructions. | FORM APPROVED OMB NO. 1105-0008 | |
|---|---|---|---|
| 1. Submit to Appropriate Federal Agency: | |||
| FTCA Claims Administrator c/o General Counsel FBI Headquarters, 935 Pennsylvania Avenue, NW Washington, D.C. 20535-0001 | |||
| 3. TYPE OF EMPLOYMENT | 4. DATE OF BIRTH | 5. MARITAL STATUS single | 6. DATE AND DAY OF ACCIDENT summer of 1996; before and after |
| 8. BASIS OF CLAIM (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and property involved, the place of occurrence and the cause thereof. Use additional pages if necessary). See Addendum | |||
| 9. PROPERTY DAMAGE | |||
| NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code). | |||
| N/A | |||
| BREAKLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED. (See instructions on reverse side). | |||
| N/A | |||
| 10. PERSONAL INJURYWRONGFUL DEATH | |||
| STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DUE OF HEAT, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE THE NAME OF THE INJURED PERSON OR DECEDENT. | |||
| This claim is on behalf of and as well as all other Epstein victims trafficked in the Epstein sex trafficking conspiracy after August 29, 1996. As a result of negligent failures, acts and omissions detailed in the Addendum, Mses. and along with many other victims have suffered from the Epstein sex trafficking conspiracy. | |||
| 11. WITNESSES | |||
| NAME | ADDRESS (Number, Street, City, State, and Zip Code) | ||
| See Addendum | |||
| 12. (See Instructions on reverse). AMOUNT OF CLAIM (in dollars) | |||
| 12a. PROPERTY DAMAGE | 12b. PERSONAL INJURY | 12c. WRONGFUL DEATH | 12d. TOTAL (Failure to specify may cause forfeiture of your rights). |
| N/A | $600 million | N/A | $600 million |
| I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN FULL Satisfaction AND FINAL Settlement OF THIS CLAIM. | |||
| 13a. PRESENTATION ON REVERSE Side. | 13b. PHONE NUMBER OF PERSON SIGNING FORM 07-20-23 | ||
| N/A | CRIMINAL PENALTY FOR PRESENTING FRADULEL CLAIM OR MAKING FALSE STATEMENTS Fine, imprisonment, or both. (See 18 U.S.C. 287, 1001.) | ||
| 16. | Sergey Brin |
| 17. | Anne Wojcicki |
| 18. | Anne Regan |
| 19. | Igor Zinoviev |
| 20. | Miles Alexander |
| 21. | Catherine Alexander |
| 22. | Larry Visoski |
| 23. | David Rodgers |