EFTA00155078.pdf

Merson Law, PLLC Merson Law, PLLC MLAW Pena; ra ia O ice svww.mersonlaw.corn Please mail all correspondence to NY office February 15, 2024 VIA PERSONAL SERVICE Federal Bureau ofInvestigation Federal Bureau of 935 Pennsylvania Avenue, NW Investigation 26 Federal Plaza, Washington D.C. 20535 23rd Floor New York New York 10278 Re: Service of Standard Form 95 Dear Ma'am/Sir: Si • closed 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, scicrenerra) Jordan Merson rim end: EFTA00155078  INSTRUCTIONS: Please read carefully the instructions on the FORM APPROVED CLAIM FOR DAMAGE, OMB NO. 1105-0008 reverse side and supply information requested on both sides of this INJURY, OR DEATH form. Use additional sheet(s) if necessary. See reverse side for additional Instructions. 1. Submit to APPreprlete Federal Agency. 2. Nemo, address of claimant, and claimant's personal repreMetegve If any. (Sue instattions on reverse). Number, Street City, Slate end Zip code. Federal Bureau of Investigation, J. Edgar Hoover Building, 935 Pennsylvania Avenue, NW, Washington, D.C. 20535 , o T erson aw, PLLC, 3. TYPE OF EMPLOYMENT 4. DATE OF BIRTH STATUS 6. DATE ANO DAY OF ACCIDENT T. TIME (AM. OR P.M.) El MILITARY iST CIVILLAN 2004-2016 Various/Multiple 8. BASIS OF ant (Stale in dotal the known is an circumrt. a the damage. I jury, or death. Identifying porecns and property invoived. the place of °court:ince and the abase thereof. Use additional pages II 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, wrongful acts, and/or omissions of the Federal Bureau of Investigation ("FBI"). Specifically, despite the fact that In 1996, rted to the FBI that the had been sexually abused by Epstein, reports from the Palm Beach police in 2005-6, 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 6.1019. B. PROPERTY DAMAGE NAME AND ADDRESS OF OWNER, IF OTHER THAN CIAIMANT (Number, Street City, State, end Zip Code). None BRIEFLY DESCRIBE THE PROPERTY. NATURE ANO EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED. (See instructions en mono We). None. 10. PERSONAL INJURY/WRONGFUL DEATH STATE THE NATURE AND EXTENT OF EACH INJURYOR CAUSE OF DEATH. WHICH FORMS TIE BASIS OF THE CLAN. IF OTTER THAN CLAIMANT, STATE THE NAME OF THE INJURED PERSON OR DECEDENT. 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. 11. WITNESSES NAME ADDRESS (Number. Street, City, Mate, end Zip Cods) 12. (See haus-bons on reverse). AMOUNT OF CLAN On dollars) 12e. PROPERTY DAMAGE 12b. PERSONAL INJURY IN. WRONGFUL DEATH 12d. TOTAL (FaOuro to spec* may cause lode) ma of you Gas). 20,000,000 20,000,000 I CERTFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURES CAUSED BY THE INCIDENT ABOVE MID AGREE TO ACCEPT SAID AMOUNT IN FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM. 13a. SIGNATURE OF CLAIMANT (Soo Instructions on rovers* sloe). 130. PHONE NUMBER OF PERSON SIGNING FORM 14, DATE OF SIGNATURE 12/02/2024 (Feb RILMEEIDGiNFESOIRESENT1NG CRIMINAL PENALTY FOR PRESENTING FRAUDULENT FRAUDULENT CLAN CLAIM OR AMONG FALSE STATEMENTS The claimant is liable to the United Slates Government fora civil penalty of not less ten Fee, imptlsonmont, or both. (See 18 U.S.C. 287. 1001.) $5,000 and not niece than $10,000, plus 3 ernes the arrant of damages Sthibbiled by the Government. (See 31 U.S.C. 3729). Authorized for Local Reproduction NSN 7540.00.634.4046 STANDARD FORM 95 (REV. 2/2007) Previous Edition is not Usable PRESCRIBED BY DEPT. OF JUSTICE 28 CFR 14.2 95-109 EFTA00155079  INSURANCECOVERAGE In dderftlit subrogation deka may be adledMated, Ills essential That the claimant provide the Mowing Inlarnetbn regarding the Insurance coverage of the vehicle ce properly. 16. CIO you carry accident Insurance? ❑ Yes eyes, give name and address of Insurance convexly (Number. Street City. State. and Zip Code) and poky mentor. jg No None. 18. Have you fled a claim with your Maecenas carrier In Ns Instance. and if so, 's It full coverkeddeciudiaM? 0 Yes OM 17- if deduCtible. state amount. None. 0.00 18. Ea WSW has been Ned with your canter, what action hes your Insurer taken or proposed to take with reference to your Mk? (ft is necessary that you ascend!) twee fads). None. 19 Do you carry pang kb i ry and properly damage Insurance? El Yes Kw:waive mane and address ofInswence carder (Mater. Street City, State end Zip Code). 0 No None. 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. A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL DAMAGES IN A SUM CERXAM FOR NJURY TO OR LOSS OF PROPERTY, PERSONAL AGENCY RECEIVES FROM A CLAIMANT. HIS DULY AUTHORiZED ACENT. OR LEGAL INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY REASON OF THE INCIDENT. REPRESENTATIVE. AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN THE CLAW MUST BE PRESENTED TO THE APPROPRIATE FEDERAL AGENCY WITHIN NOTIFICATION OF AN INCIDENT. ACCOMPANIED BY A CLAIM FOR MONEY TWO_YEARS AFTER TUE CLAIM ACCRUES. Failure to completely execute this form or to supply the requested malarial within The amount claimed should be substantiated by pampa:am evidence es News: two year:: from the date the cairn accrued may renal your claim Invalid. A claim is deemed presented when It Is received by the appropriate agency, not when It Is (a) In support of the claim for personal enury or death, the calmed should submit a malted. written report by the atlenckg physician, shearing the naPert and of ent of the Nunn the nature and extent et treatment. the degree of perm-mere dIsabay. 0 any, Ine prognosis. and the pedalo! hospitaltmlien, or Incepadttefon. 'electing Itemized Nis for mafiosi, If Instruabn Is needed In ccendonng this form, the agency listed In kern/Hon the reverse hospeol. or burial expenses actially incurred, side may be contacted. Complete regulations pen/MIMI to claims anemia under the Federal Tat Claim Act can be found In Tine 28. Code or Federal Regulations. Part 14. Many agendas haw published supplemenertg regulations. If mom than ore agency 4 (b) to supped of daims for *Wage to Properly. wt4di has boon or can be economically inweved. Please slate mar legerwib repaked, the claimant should submit at least two itemized signed statements or estimates by reliable, timbre:mod concerns, or, if payment has been made, the Nomtred (pad rerdllis eddendog payment. The claim may be Med by a duly authocked agent or other ktital representative, provided weldor:co tonsfaday to trie Government Is submitted with Me claim establishing express authority to xl for the claimant. A Calm presented by on agent or legal roprosentnave (c) In support of clams kr damage to property which Is not oconomimly repairable, dal must be presented In the name of the claimed. II the Mini is signed by the agent or thn property Is Yost or destroyed. Ilse claimant should setae statements as to the orgind Mad reereseresere. it must show the NM or loyal capacity of the person signing and bo emit or the property. the date of purchase, and the valve d the property, both before and accompanied by evidence of Neer authority to present a claim on behalf of the claimant alter the accident Such statements eisculd be by *animated competent persons. as aged, emoted, adniristrator. parent, guardian or other remmentattve. preferably reputable deem; or dliciaM fanny with the type of property damaged, or by two or more competikm bidders and should be cemeed as being lust and mere. II askant 'Mandeb No for both personal Wm and propeny Carnage, the amount for each not be sheen In km number 12 of Me km. gl) Fauna to specify • item certain wit render your claim Invalid and may result in forfolture of your doles. PRIVACY ACT NOTICE TM Notice is provided h accordance with Uo Privacy/4d. 5 U.S.C. 552a(e)(3). and B. MindedPurpose: The inky:nolo° requested iv to be used In evaluating dolma concerns the infiwnallon requested in the letler to whIct this Nokia Is attached. C. Routine Use: See the Notices of Systems of Records la the agency to whom you am A. Authority: The requested Information Is sdkitod pursuant to ono or mere of the sulanttelig IMP:Int& thiS Information. following 5 U.S.C. 301. 26 U.S.C. 601 el sal.. 28 U.S.C. 2671 et seq., 28 C.F.R. 0. Med ofFeeure to Raspier!: (Mclean is voluntary. However. faro to supply ale' Part 14. requested Information or to execute tee form may raider your clean •invalid• PAPERWORK REDUCTION ACT NOTICE TN, relic° to Addy for the purpose of the Paperwork Reduction Act. 44 U.S.C. 3501. Public reporting burden for Na collection of 1r4orrna0en Is enamored le average B hours pce response. Including the time for reviewing insMictioro, searching existing data sources. gathering and 11181.11aliing am data needed, and completing and reviewing rho collection of information. Send comments regard:1g th a burden earn or any otter aspect of this Median of interment:in, Including soegestons La reducing CM burden, to the master. Toed Bream. Monson: Paponvork Reduction Steff, ad °Melon. U.S. Department or Justice. Washington, DC 20630 or to the atm of Management and Budget Do not mat completed fonds)to these addresses. STANDARD FORM 95 REV. (2/2007) BACK EFTA00155080  final SF95-07a Final Audit Report 2024-02-12 Created: 2024-02-12 By: KerneIto Dein Status: Signed Transaction ID: CBJCHBCPABAAhMCBSdJOOBVBTK-s0sUL2RIDIVebFz7n final SF95-07a" History in Document created by Kameile Delfin 2024-02-12 - 5:10:08 PM GMT- IP address: El Document emailed tc or signature 2024-02-12 - 5:1012 PM GMT 5 Email viewed by 2024-02-12 - 5:1049 PM GMT- IP address e5o Document e-signed by Signature Date: 2024-02-12 - 10:07:14 PM GMT - lime Source: server- IP addres CD Agreement completed. 2024-02-12 - 10:07:14 PM GIST Adobe Acrobat Sign EFTA00155081