Please mail all correspondence to NY office¶
February 15, 2024¶
VIA PERSONAL SERVICE¶
Federal Bureau of Investigation¶
935 Pennsylvania Avenue, NW¶
Washington, D.C. 20535¶
Federal Bureau of Investigation 26 Federal Plaza, 23rd Floor New York, New York 10278¶
Re: Service of Standard Form 95¶
Dear Ma’am/Sir:¶
Enclosed for service, please find a signed Standard Form 95 for Claimant 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,¶
Jordan Mosa¶
Jordan Merson¶
/jm¶
encl:¶
EFTA00155078¶
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 sheet(s) if necessary. See reverse side for additional instructions.¶
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Submit to Appropriate Federal Agency:
- Federal Bureau of Investigation, J. Edgar Hoover Building, 935 Pennsylvania Avenue, NW, Washington, D.C. 20535
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Name, address of claimant, and claimant’s personal representative if any:
- Name, address of claimant, and claimant’s personal representative if any.
- (See Instructions on reverse.) Number, Street, City, State and Zip code.
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TYPE OF EMPLOYMENT
- MILITARY
- CIVILIAN
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DATE OF BIRTH
- 4月27日
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MARITAL STATUS
- 6月18日
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DATE AND DAY OF ACCIDENT
- 2004-2016
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TIME (A.M. OR P.M.)
- Various/Multiple
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BASIS OF CLAIM (State is stated the known facts and circumstances of the damage, injury, or death, identifying persons and property involved, the place of occurrence and the cause thereof. Use additional pages if necessary).
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 negligence, wrong acts, and/or omissions of the Federal Bureau of Investigation (“FBI”). Specifically, despite the fact that in 1998, reports from the Palm Beach police in 2008-6, 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.¶
- PROPERTY DAMAGE
NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code).¶
None¶
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).¶
None.¶
- PERSONAL INJURY/WRONGFUL DEATH
STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. If OTHER THAN CLAIMANT, STATE THE NAME OF THE INJURED PERSON OR DECIDENT.¶
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.¶
- WITNESSES
| NAME | ADDRESS (Number, Street, City, State, and Zip Code) |
|---|---|
- SEE INSTRUCTIONS ON REVERSE).
AMOUNT OF CLAIM (in dollars)¶
12a. PROPERTY DAMAGE 12b. PERSONAL INJURY 20,000,000 12c. WRONGFUL DEATH 20,000,000¶
- 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. SIGNATURE OF CLAIMANT (See instructions on reverse side).¶
13b. PHONE NUMBER OF PERSON SIGNING FORM¶
- DATE OF SIGNATURE 12/02/2024
Feb 14, 2024 WEEKEND PRESENTING FRADUOLIENT CLAIM¶
The claimant is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages sustained by the Government. (See instructions on reverse side).¶
Authorized for Local Reproduction Previous Edition is not Usable¶
95-109¶
NSN 7540-00-634-4046¶
STANDARD FORM 95 (REV. 2/2007) PRESCRIBED BY DEPT. OF JUSTICE 28 CFR 14.2¶
EFTA00155079¶
INSURANCE COVERAGE¶
In order that subrogation claims may be adjudicated, it is essential that the claimant provides the following information regarding the insurance coverage of the vehicle or property.¶
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Do you carry accident Insurance? ☑ Yes If yes, give name and address of insurance company Number, Street, City, State, and Zip Code) and policy number. ☐ No
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Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage of deductible? ☑ Yes ☐ No 17. if deductible, state amount. None. 0.00
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If it claim has been filed with your carrier, what action has your Insurer taken or proposed to take with reference to your claim? It is necessary that you assemble these facts). None.
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Do you carry public liability and property damage insurance? ☑ Yes If yes, give name and address of insurance carrier (Number, Street, City, State, and Zip Code). ☐ No None.
CLAims presented under the Federal Tort Claims Act should be submitted directly to the “appropriate Federal agency” whose employee(s) was involved in the incident. If the incident involves more than one claimant, each claimant should submit a separate claim form.¶
Complete all items – Insert the word NONE where applicable.¶
A CLAIM SHALL BE DEFINED TO HAVE BEEN PRESENTED WHEN A PERSONAL AGENCY RECEIVES FROM A CLAIMANT, HIS DAY AUTHORIZED AGENT, OR LEGAL REPRESENTATIVE, AN EXECUTIVE STANDARD FORM 96 OR OTHER WRITTEN NOTIFICATION OF AN INCIDENT, ACCOMPARED BY A CLAIM FOR MONEY¶
Failure to completely comply with the requirement of supply the requested material within the time specified must be addressed by the appropriate agency, not when it is mailed.¶
If instruction is needed in completing this form, the agency listed in Item #1 on the reverse side may be contended. Complaint regulations shall be submitted under the Federal Tort Claims Act Title 25, Code of Federal Regulations, Part 14. The agency responsible for submitting the complaint. If none is involved, please state each agency.¶
The claim may be filed by a duly authorized agent or other legal representative, provided evidence satisfactory to the Government is submitted with the claim establishing express authority to be for the claimant. A claim presented by an agent or legal representative must be presented in the name of the claimant. If the claimant is signed by the agent or legal representative, the claimant must be accompanied by evidence of either authority to present a claim on behalf of the claimant as agent, executor, administrator, pawn, guarder or other representative.¶
If claimant is intended to be for both personal injury and property damage, the amount for each must be shown in item 12 of this form.¶
INSTRUCTIONS¶
Claims presented under the Federal Tort Claims Act should be submitted directly to the “appropriate Federal agency” whose employee(s) was involved in the incident. If the incident involves more than one claimant, each claimant should submit a separate claim form.¶
Complete all items – Insert the word NONE where applicable.¶
DAMAGES IN A SUM CERTAIN FOR INJury TO OR LOSS OF PROPERTY, PERSONAL INJury, OR CREATE ALLEGED BY REASON OF THE INCIDENT. THE CLAIM MUST BE PRESENTED TO THE APPROPRIATE Federal Agency WITHIN TWO YEARS AFTER THE CLAIM ACCREDITS.¶
The amount claimed should be substantiated by competent evidences as follows:¶
(a) In support of the claim for personal injury or death, the claimant should submit a written report from the attending physician, showing the nature and extent of the injury, the nature and extent of treatment, the degree of permanent disability, if any, perigraphed, and the period of hospitalization, or incapacitation, attaching relevant lists of medical, hospital, or burial expenses actually incurred.¶
(b) In support of claims for damage to property, which has been or can be economically required, the claimant should submit at least two terminated signed statements or estimates by mobile, discontinued concerns, or if payment has been made, the Remitted signed payment.¶
(c) In support of claims for damage to property which is not economically repairable, or if the property is lost or destroyed, the claimant should submit statements as to the original condition of the property and the date and location of the incident. Such statements should be submitted by disinterested competent persons, or by two or more competitive bidders, and be on par with the type of property damaged¶
STANDARD FORM 95 REV. (2/2007) BACK¶