EFTA01649853.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 emailbox by October 4, 2019. Full Name: Email Address: Phone Number: Click here to enter phone nUIT;Uc; Social Security Number: Click here to enter SSN Address 1: Click here to enter address 1 Address 2: I ic'e to enter address 2 City: Click here to enter city State: Click here to enter state Zip: Click here to enter zip Citizenship: Click here to enter citizenship Country of Birth: lck here to enter country of birth If you have spoken with a FBI Victim Specialist, please provide their name: Click here to enter VS name Can you attend? Yes, I will attend 0 No, I cannot attend If yes, which location will you attend? 0 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 0 No, I will not need travel arrangements If yes, which mode of transportation do you prefen Air LI: 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. Date of Birth (required by airlines): Click here to enter date of birth Airport of origin: Preferred time of travel: Click here to enter preferred time of travel Click here to enter departure airport name 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 2 No, I will not require lodging Do you require airport transportation? Yes, I will require transportation to/from the airport D No, I will not require transportation to/from the airport EFTA01649853 Support person n •nn o Support Person's Name: Name as it appears on government issued ID Relationship: Click here to enter relationship Email Address: Click here to enter email address Phone Number: Click here to enter phone number Social Security Number: Click here to enter SSN Address 1: Click here to enter address 1 Address 2: Click here to enter address 2 City: C lick here to enter city State: Click here to enter state Zip: Click here to enter zip Citizenship: Click here to enter citizenship Country of Birth: Click here to enter country of birth Will your support person need travel arrangements? Yes, my support person will need travel arrangements No, my support person will not need travel arrangements If yes, which mode of transportation do they prefer? ❑ Air E Rail ❑ Bus E 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. Date of Birth (required by airlines): Click here to enter date of birth Airport of origin: Preferred time of travel: Click here to enter preferred time of travel Click here to enter departure airport name If bringing a support person, will your support person require separate lodging? w 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 C 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. 0 Yes, I acknowledge the above statement Click here to enter your full name Click here to enter signature date 2 EFTA01649854