Downwinder Claim Form – Fill Out and Use This PDF

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	OMB Approval No. 1105-0052
	Revised December 2011
U.S. Department of Justice	Radiation Exposure Compensation Program
Civil Division	Downwinder Claim Form

Claim form for cases filed under the Radiation Exposure Compensation Act.

General Instructions:

Read the entire claim form and complete all necessary parts. Failure to submit the required documentation will delay the processing of your claim. There are five claimant categories under the Act: uranium miner, miller, ore transporter, downwinder, and onsite participant. If you have any questions, call 1-800-729-7327 or visit our website at www.justice.gov/civil/common/reca.html. No individual may receive more than one payment under the Act. Sec. 7(b).

Part 1: YOU, the person filling out this form.

First name

Middle name

Last name

Maiden name, if applicable

Other names

Former names

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Residence address

If you are a member of an Indian Tribe, please check the relevant box below.

G Apache	G Hopi
G Navajo	G Other

Print your census number here:

If you are a member of an Indian Tribe, complete page 17.

Have you received assistance from any of the following organizations?

G Office of Navajo Uranium Workers - Shiprock Office

G Office of Navajo Uranium Workers - Tuba City Office

GOther

Part 2: THE CLAIMANT, the person who became ill with a compensable disease. If

YOU are the person who became ill you may proceed to Part 3 and are NOT required to fill out Part 2.

First name

Middle name

Last name

Maiden name, if applicable

Other names

Former names

Social Security number

Date of Birth (mm/dd/yy)

Date of Death(mm/dd/yy)

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Part 3: RELATIONSHIP TO THE PERSON WHO BECAME ILL.

Please indicate your relationship to the person who became ill and on whose behalf you are filing below and follow the appropriate directions:

Q Self (go to Part 4 on page 3)	Q Parent (go to Part 7 on page 6)
Q Spouse (go to Part 5 on page 3)	Q Grandchild (go to Part 7 on page 6)
Q Child (go to Part 6 on page 4)	Q Grandparent (go to Part 7 on page 6)

Part 4: SELF-FILERS, individuals who became ill and are filing for themselves.

A SELF-FILER must submit the following certified or original documents: To process this claim you will need to provide certified or original copies of the information requested in this claim form (photocopies, even if notarized, are not sufficient unless certified by the issuing institution). All original documents will be returned when this claim is resolved.

G Birth certificate: yours.

G Marriage certificate(s): documenting any and all changes of name, if applicable.

•If you are a SELF-FILER please continue to Part 8 of the claim form. You should NOT fill out Parts 5, 6, and 7.

Part 5: SURVIVING SPOUSE, the individual who was married to the person who became ill for at least one year prior to his or her death.

Please answer the following questions:

Is the person identified in Part 2 deceased? If "NO", you are not eligible to file this claim.

YES [ ] NO [ ]

Were you married to the claimant, the person who became ill, for at least one year immediately prior to his or her death? If "NO", you are not eligible to file this claim.

YES [ ] NO [ ]

Was the person who became ill married to anyone else BEFORE he or she married you?

YES [ ] NO [ ]

If yes, please list the name of each previous spouse and the dates which the marriage began and ended.

_______________________________________________________________________________

_______________________________________________________________________________

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Have you ever been married to anyone else other than the person who became ill?

YES [ ] NO [ ]

If yes, please list the name of each spouse and the dates which the marriage began and ended.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

A SPOUSE must submit the following certified or original documents:

To process this claim you will need to provide certified or original copies of the information requested in this claim form (photocopies, even if notarized, are not sufficient unless certified by the issuing institution). All original documents will be returned when this claim is resolved.

G Birth certificate: of the person who became ill.

G Death certificate: of the person who became ill.

G Marriage certificate: documenting your marriage to the person who became ill.

G Marriage certificate(s): documenting any previous marriages of the person who became ill, if applicable.

G Divorce decree(s) or death certificate(s): documenting the end of any previous marriages of the person who became ill, if applicable.

G Birth certificate: yours.

G Marriage certificate(s): documenting all of your other marriages, if applicable.

G Divorce decree(s) or death certificate(s): documenting the end of any of your marriages previous to your marriage to the claimant.

•If you are a SPOUSE please continue to Part 8 of the claim form. You should NOT fill out Parts 4, 6, or 7.

Part 6: SURVIVING CHILD, an individual who was a natural, adopted, or step-child of the person who became ill.

Please answer the following questions:

Is the person identified in Part 2 (the person who became ill) deceased? If "NO", you are not eligible to file this claim.

YES [ ] NO [ ]

Was the person who became ill ever married?

YES [ ] NO [ ]

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If YES, list the name of each spouse, the date and place each marriage began, and the date and place of divorce or death of each spouse of the person who became ill.

________________________________________________________________________________

______________________________________________________________________________

Are you a natural child, adopted child, or step-child of the decedent?

NATURAL [ ] ADOPTED CHILD [ ] STEP-CHILD [ ]

Did the decedent have any other natural, adopted, or step-children? YES [ ] NO [ ]

If so, list the name of each child, date and place of birth, phone number, and current address or date and place of death.

1)Name: ______________________________ Date and place of birth: _____________________

Date and place of death, if applicable:_________________________________________________

Current address, if applicable:_______________________________________________________

Phone number, if applicable: _______________________________________________________

2)Name: ______________________________ Date and place of birth: _____________________

Date and place of death, if applicable:_________________________________________________

Current address, if applicable:_______________________________________________________

Phone number, if applicable: _______________________________________________________

3)Name: ______________________________ Date and place of birth: _____________________

Date and place of death, if applicable:_________________________________________________

Current address, if applicable:_______________________________________________________

Phone number, if applicable: _______________________________________________________

If there are more children of the claimant please use the back of this page or attach another sheet to provide the information requested above and check here: G

A SURVIVING CHILD must submit the following certified or original documents:

To process this claim you will need to provide certified or original copies of the information requested in this claim form (photocopies, even if notarized, are not sufficient unless certified by the issuing institution). All original documents will be returned when this claim is resolved.

G Birth certificate: of the person who became ill.

G Death certificate: of the person who became ill.

G Marriage certificate(s): of the person who became ill.

G Divorce decree(s) or death certificate(s): documenting that any and all marriages of the person who became ill have ended.

G Birth certificate or papers of adoption: yours.

G Marriage certificate(s): documenting any and all of your name changes, if applicable.

GIf you are a step-child of the person who became ill, send proof that their spouse was one of your natural parents and any records which show that you lived with the person who became ill in a regular parent-child relationship (for example, school records).

G Death certificates: of any siblings that have passed away.

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