28 C.F.R. § 74 app A to Part 74
Form A:
Declaration of Eligibility by Persons Identified by the Office of Redress Administration
U.S. Department of Justice
Civil Rights Division
Office of Redress Administration
This declaration shall be executed by the identified eligible person or such person's designated representative.
Complete the following information:
(1) Current Legal Name:________________________
(2) Current Address:
Street:________________________
City, State and Zip Code:________________________
________________________
(3) Telephone Number:
________________________
(Home)
________________________
(Business)
(4) Social Security Number:________________________
(5) Date of Birth:________________________
(6) Name Used When Evacuated or Interned:________________________
Read the following carefully before signing this document. A False Statement may be grounds for punishment by fine (U.S. Code, title 31, section 3729), and fine or imprisonment or both (U.S. Code, title 18, section 287 and section 1001).
I declare under penalty of perjury that the foregoing is true and correct.
________________________
Signature
________________________
Date
Privacy Act Statement: The authority for collecting this information is contained in 50 U.S.C. app. 1989b. The information that you provide will be used principally for verifying eligible persons for payment under the restitution provision of the Civil Liberties Act of 1988.
Required Documentation: The following documentation must be submitted with the above Declaration to complete your verification.
DOCUMENTATION:
I. Identification
A document with your current legal name and address. For example, you might send a bank or financial statement, or a monthly utility bill. Submit either a notarized copy of the record or an original that you do not need back.
II. One Document of Date of Birth
A certified copy of a birth certificate or a copy of another record of birth that has been certified by the custodian of the records. For example, you might send a religious record which shows your date of birth, or a hospital birth record. If you do not have any record of your birth the Administrator will accept affidavits of two or more persons attesting to the date of your birth.
If your notification letter says that the Social Security Administration has confirmed your date of birth, you do not have to send us any further evidence of your birth date.
III. One Document of Name Change
If your current legal name is the same as your name when evacuated or interned, this section does not apply.
This section is only required for persons whose current legal name is different from the name used when evacuated or interned.
1. A certified copy of the public record of marriage.
2. A certified copy of the divorce decree.
3. A certified copy of the court order of a name change.
4. Affidavits or sworn statements of two or more persons attesting to the name change.
IV. One Document of Evidence of Guardianship
If you are executing this document for the person identified as eligible, you must submit evidence of your authority.
If you are the legally-appointed guardian, committee, or other legally-designated representative of such an individual, the evidence shall be a certificate executed by the proper official of the court appointment.
If you are not such a legally-designated representative, the evidence shall be an affidavit describing your relationship to the recipient or the extent to which you have the care of the recipient or your position as an officer of the institution in which the recipient is institutionalized.
Form B:
Declaration of Verification by Persons Identified as Statutory Heirs by the Office of Redress Administration
U.S. Department of Justice
Civil Rights Division
Office of Redress Administration
This declaration shall be executed by the spouse of a deceased eligible individual as statutory heir in accordance with section 105(a)(7) of the Civil Liberties Act of 1988, 50 U.S.C. app. 1989b.
Complete the following information:
(1) Current Legal Name:________________________
(2) Current Address:
Street:________________________
City, State and Zip Code:________________________
________________________
(3) Telephone Number:
________________________
(Home)
________________________
(Business)
(4) Social Security Number:________________________
(5) Date of Birth:________________________
(6) Relationship to the Deceased:________________________
(8) Date of marriage to the Deceased:________________________
Read the following carefully before signing this document.
A False Statement may be grounds for punishment by fine (U.S. Code, title 31, section 3729), and fine or imprisonment or both (U.S. Code, title 18, sections 287 and section 1001).
I declare under penalty of perjury that the foregoing is true and correct.
________________________
Signature
________________________
Date
Privacy Act Statement: The authority for collecting this information is contained in 50 U.S.C. app. 1989b. The information that you provide will be used principally for verifying eligible persons for payment under the restitution provision of the Civil Liberties Act of 1988.
Required Documentation: The following documentation must be submitted with the above Declaration to complete your verification.
DOCUMENTATION:
I. One Document as Evidence of the Deceased Eligible Individual's Death
1. A certified copy or extract from the public records of death, coroner's report of death, or verdict of a coroner's jury.
2. A certificate by the custodian of the public record of death.
3. A statement of the funeral director or attending physician, or intern of the institution where death occurred.
4. A certified copy, or extract from an official report or finding of death made by an agency or department of the United States.
5. If death occurred outside the United States, an official report of death by a United States Consul or other employee of the State Department, or a copy of public record of death in the foreign country.
6. If you cannot obtain any of the above evidence of your spouse's death, you must submit other convincing evidence to ORA such as the signed statements of two or more people with personal knowledge of the death, giving the place, date, and cause of death.
II. One Document as Evidence of Your Marriage to the Deceased Eligible Individual
1. A copy of the public records of marriage, certified or attested, or an abstract of the public records, containing sufficient data to identify the parties, the date and place of marriage, and the number of prior marriages by either party if shown on the official record, issued by the officer having custody of the record or other public official authorized to certify the record, or a certified copy of the religious record of marriage.
2. An offical report from a public agency as to a marriage which occurred while the deceased eligible individual who was employed by such agency.
3. The affidavit of the clergyman or magistrate who officiated.
4. The certified copy of a certificate of marriage attested to by the custodian of the records.
5. The affidavits or sworn statements of two or more eyewitnesses to the ceremony.
6. In jurisdictions where "Common Law" marriages are recognized, the affidavits or certified statements of the spouse setting forth all of the facts and circumstances concerning the alleged marriage, such as the agreement between the parties at the beginning of their cohabitation, places and dates of residences, and whether children were born as the result of the relationship. This evidence should be supplemented by affidavits or certified statements from two or more persons who know as the result of personal observation the reputed relationship which existed between the parties to the alleged marriage, including the period of cohabitation, places of residences, whether the parties held themselves out as husband and wife and whether they were generally accepted as such in the communities in which they lived.
7. Any other evidence which would reasonably support a belief by the Administrator that a valid marriage actually existed.
III. Identification
A document with your current legal name and address. For example, you might send a bank or financial statement or a monthly utility bill. Submit either a notarized copy of the record or an original that you do not need back.
IV. One Document of Date of Birth
A certified copy of a birth certificate or a copy of another record of birth that has been certified by the custodian of the records. For example, you might send a copy of a religious record which shows your date of birth, or a hospital birth record. If you do not have any record of your birth, the Administrator will accept affidavits of two or more persons attesting to the date of your birth.
If your notification letter says that the Social Security Administration has confirmed your date of brith, you do not have to send us any further evidence of your birth date.
V. One Document of Name Change
If your current legal last name is the same as the last name of the deceased eligible individual or the same as at the time of marriage this section does not apply.
This section is only required for persons whose current legal last name is different from the last name of the deceased eligible.
1. A certified copy of the public record of marriage.
2. A certified copy of the divorce decree.
3. A certified copy of the court order of a name change.
4. Affidavits or sworn statements of two or more persons attesting to the name change.
VI. One Document of Evidence of Guardianship
If you are executing this document for the person identified as eligible, you must submit evidence of your authority.
If you are the legally-appointed guardian, committee, or other legally-designated representative of such an individual, the evidence shall be a certificate executed by the proper official of the court appointment.
If you are not such a legally-designated representative, the evidence shall be an affidavit describing your relationship to the recipient or the extent to which you have the care of the recipient or your position as an officer of the institution in which the recipient is institutionalized.
Form C:
Declaration of Verification by Persons Identified by the Office of Redress Administration as Statutory Heirs
U.S. Department of Justice
Civil Rights Division
Office of Redress Administration
This declaration shall be executed by the child of a deceased eligible individual as a statutory heir in accordance with section 105(a)(7) of the Civil Liberties Act of 1988, 50 U.S.C. app. 1988b.
Complete the following information:
(1) Current Legal Name:________________________
(2) Current Address:
Street:________________________
City, State and Zip Code:________________________
________________________
(3) Telephone Number:
________________________
(Home)
________________________
(Business)
(4) Social Security Number:________________________
(5) Date of Birth:________________________
(6) Relationship to the Deceased:________________________
(7) List the names and address (if known) of all other children of the deceased eligible individual. This includes all recognized natural children, step-children who lived with the deceased eligible and adopted children. Enter the date of death for any persons who are deceased.
________________________
________________________
________________________
________________________
Read the following carefully before signing this document. A False Statement may be grounds for punishment by fine (U.S. Code, title 31, section 3729), and fine or imprisonment or both (U.S. Code, title 18, section 287 and section 1001).
I declare under penalty or perjury that the foregoing is true and correct.
________________________
Signature
________________________
Date
Privacy Act Statement: The authority for collecting this information is contained in 50 U.S.C. app. 1989b. The information that you provide will be used principally for verifying eligible persons for payment under the restitution provision of the Civil Liberties Act of 1988.
Required Documentation for Children of Deceased Eligible Individual
The following documentation must be submitted with the above Declaration to complete your verification.
DOCUMENTATION:
I. One Document as Evidence of Your Parent's Death
1. A certified copy or extract from the public records of death, coroner's report of death, or verdict of a coroner's jury.
2. A certificate by the custodian of the public record of death.
3. A statement of the funeral director or attending physician, or intern of the institution where death occurred.
4. A certified copy, or extract from an official report or finding of death made by an agency or department of the United States.
5. If death occurred outside the United States, an official report of death by a United States Consul or other employee of the State Department, or a copy of public record of death in the foreign country.
6. If you cannot obtain any of the above evidence of your parent's death, you must submit other convincing evidence to ORA such as the signed statements of two or more people with personal knowledge of the death, giving the place, date, and cause of death.
II. One Document as Evidence of Your Relationship to Your Parent
Natural Child
1. A certified copy of a birth certificate showing that the deceased eligible individual was your parent.
2. If the birth certificate does not show the deceased eligible individual as your parent, other proof would be a certified copy of:
(a) An acknowledgment in writing signed by the deceased eligible individual.
(b) A judicial decree ordering the deceased eligible individual to contribute to your support or for other purposes.
(c) A certified copy of the public record of birth or a religious record showing that the deceased eligible individual was the informant and was named as your parent.
(d) Affidavits or sworn statements of a person who knows that the deceased eligible individual accepted the child as his or hers.
(e) A record obtained from a public agency or public records, such as school or welfare agencies, which shows that with the deceased eligible individual's knowledge, the deceased eligible individual was named as the parent of the child.
Adopted Child
Evidence of the relationship by an adopted child must be shown by a certified copy of the decree of adoption. In jurisdictions where petition must be made to the court for release of adoption documents or information, or where the release of such documents or information is prohibited, a revised birth certificate will be sufficient to establish the fact of adoption.
Step-Child
Submit all three as evidence of the step-child relationship.
1. One document as evidence of birth to the spouse of the deceased eligible individual as listed under the "natural child" and "adoptive child" sections to show that you were born to or adopted by the deceased individual's spouse, or other evidence which reasonably supports the existence of a parent-child relationship between you and the spouse of the deceased eligible person.
2. One document as evidence that you were either living with or in a parent-child relationship with the deceased eligible individual at the time of the eligible individual's death.
3. One document as evidence of the marriage of the deceased eligible individual and the spouse, such as a copy of the record of marriage, certified or attested, or by an abstract of the public records, containing sufficient data to identify the parties and the date and place of marriage issued by the officer having custody of the record, or a certified copy of a religious record of marriage.
III. Identification
A document with your current legal name and address. For example, you might send a bank or financial statement, or a monthly utility bill. Submit either a notarized copy of the record or an original that you do not want back.
IV. One Document of Date of Birth
A certified copy of a birth certificate or a copy of another record of birth that has been certified by the custodian of the records. For example, you might send a copy of a religious record which shows your date of birth, or a hospital birth record. If you do not have any record of your birth, the Administrator will accept affidavits of two or more persons attesting to the date of your birth.
If your notification letter says that the Social Security Administration has confirmed your date of birth, you do not have to send us any further evidence of your birth date.
V. One Document of Name Change
If your current legal last name is the same as the last name of the deceased eligible, this section does not apply.
This section is only required for persons whose current legal last name is different from the last name of the deceased eligible.
Submit one of the following as evidence of the change of legal name.
1. A certified copy of the public record of marriage.
2. A certified copy of the divorce decree.
3. A certified copy of the court order of a name change.
4. Affidavits or sworn statements of two or more persons attesting to the name change.
VI. One Document of Evidence of Guardianship
If your are executing this document for the person identified as an eligible beneficiary, you must submit evidence of your authority.
If you are a legally-appointed guardian, committee, or other legally-designated representative of such an individual, the evidence shall be a certificate executed by the proper official of the court appointment.
If you are not such a legally-designated representative, the evidence shall be an affidavit describing your relationship to the recipient or the extent to which you have the care of the recipient or your position as an officer of the institution in which the recipient is institutionalized.
Form D:
Declaration of Verification by Persons Identified by the Office of Redress Administration as Statutory Heirs
U.S. Department of Justice Civil Rights Division Office of Redress Administration
This declaration shall be executed by the identified parent of a deceased eligible individual as statutory heir in accordance with
Section 105(a)(7) of the Civil Liberties Act of 1988, 50 U.S.C. app. 1989b.
Complete the following information:
(1) Current Legal Name:________________________
(2) Current Address:________________________
Street:________________________
City, State and Zip Code:________________________
(3) Telephone Number:________________________
(Home)________________________
(Business)________________________
(4) Social Security Number:________________________
(5) Date of Birth:________________________
(6) Relationship to the Deceased:________________________
(7) The name of the child's other parent and the address if known. This includes fathers and mothers through adoption. If the parent is deceased provide the date and place of death.________________________
Read the following carefully before signing this document. A False Statement may be grounds for punishment by fine (U.S. Code, title 31, section 3729), and fine or imprisonment or both (U.S. Code, title 18, section 287 and section 1001).
I declare under penalty of perjury that the foregoing is true and correct.
Signature________________________
Date________________________
Privacy Act Statement: The authority for collecting this information is contained in 50 U.S.C. app. 1989b. The information that you provide will be used principally for verifying eligible persons for payment under the restitution provision of the Civil Liberties Act of 1988.
Required Documentation.
The following documentation must be submitted with the above Declaration to complete your verification.
DOCUMENTATION:
I. One Document as Evidence of Your Child's Death
1. A certified copy or extract from the public records of death, coroner's report of death, or verdict of a coroner's jury.
2. A certificate by the custodian of the public record of death.
3. A statement of the funeral director or attending physician, or intern of the institution where death occurred.
4. A certified copy, or extract from an official report or finding of death made by an agency or department of the United States.
5. If death occurred outside the United States, an official report of death by a United States Consul or othe employee of the State Department, or a copy of public record of death in the foreign country.
6. If you cannot obtain any of the above evidence, you must submit other convincing evidence to ORA such as the signed statements of two or more people with personal knowledge of the death, giving the place, date, and cause of death.
II. One Document as Evidence of Your Parent-Child Relationship Natural Parent
1. A certified copy of a birth certificate that shows you to be the deceased eligible individual's parent.
2. A certified acknowledgment in writing signed by you before the eligible individual's death.
3. Any other evidence which reasonably supports a finding of such a parent-child relationship, such as a certified copy of the public record of birth or a religious record showing that you were the informant and were named as the parent of the deceased eligible individual.
4. Affidavits or sworn statements of persons who know that you had accepted the deceased eligible individual as his or her child.
5. Information obtained from a public agency or public records, such as school or welfare agencies, which shows that with the deceased eligible individual's knowledge, you were named as parent.
Adoptive Parent
1. A certified copy of the decree of adoption and such other evidence as may be necessary.
2. In jurisdictions where petition must be made to the court for release of such documents or information, or where release of such documents or information is prohibited, a revised birth certificate showing the person as the deceased eligible individual's parent will suffice.
III. Identification
A document with your current legal name and address. For example, you might send a bank or financial statement, or a monthly utility bill. Submit either a notarized copy or an original that you do not need back.
IV. One Document of Date of Birth
A certified copy of a birth certificate or a copy of another record of birth that has been certified by the custodian of the records. For example, you might send a copy of a religious record which shows your date of birth, or a hospital birth record. If you do not have any record of your birth, the Administrator will accept affidavits of two or more persons attesting to the date of your birth.
If your notification letter says that the Social Security Administration has confirmed your date of birth, you do not have to send any further evidence of your birth date.
V. One Document of Name Change
If your current legal last name is the same as the last name of the deceased eligible individual this section does not apply.
This section is only required for persons whose current legal last name is different from the last name of the deceased eligible.
1. A certified copy of the public record of marriage.
2. A certified copy of the divorce decree.
3. A certified copy of the court order of a name change.
4. Affidavits or sworn statements of two or more persons attesting to the name change.
VI. One Document of Evidence of Guardianship
If you are executing this document for the person identified as eligible, you must submit evidence of your authority.
If you are the legally-appointed guardian, committee, or other legally-designated representative of such an individual, the evidence shall be a certificate executed by the proper official of the court appointment.
If you are not such a legally-designated representative, the evidence shall be an affidavit describing your relationship to the recipient or the extent to which you have the care of the recipient or your position as an officer of the institution in which the recipient is institutionalized.
28C.F.R. 74 app A to Part 74