Merson Law, PLLC Merson Law, PLLC M LAW Www. Mersonlaw,com Please mail all correspondence to NY office February 15, 2024 VIA PERSONAL SERVICE Federal Bureau of Investigation Federal Bureau of 935 Pennsylvania Avenue, NW Investigation 26 Federal Pisze, Washington. D.C. 20535 23rd Floor N Re: Service of Standard Form 95 Dear Ma’am/Sir: Enclosed for service, please find a signed Standard Form 95 for Claimant a. , 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, ode, Jordan Merson jim encl: EFTA00155074

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CLAIM FOR DAMAGE, INSTRUCTIONS: Piease read carefully the instructions on the reverse side and supply information requested on both sides of this | OMB NO. 1105-0008 INJURY, OR DEATH form. Use additional sheet(s) if necessary. Seo reverse side for additional instructions. 1. Subralt to Appropriate Federal Agency: 2, Namo, addrass of claimant, and claimant's personal ropresentative If any. (Sea instructions on reverse). Number, Street, City, State and Zip code. Federal Bureau of Investigation, J, Edgar Hoover Building, 935 Pennsylvania Avenue, NW, Washington, D.C. 20535 c/o Merson au PLLC, 3. TYPE OF EMPLOYMENT 4. DATE OFGIRTH [6 MARITALSTATUS | 6, DATE AND DAY OF ACCIDENT 7. TIME (AM. ORPM) Cimurary Xfcvenn | 2004-2006 _| Various/Multipie 8. BASIS OF CLAIM (State in detail the known facts and cires u Gamage, injury, or dealh, 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 SE ciinanr) at the hands of Jeffrey Epstein ("Epstein") as a result of the gross negli acts, and/or omissions of the Federal Bureau of investigation ("FBI"). Specifically, despite the fact that in 1996, reported to the FBI that she had been sexually abused by Epstein, reports from the Palm Beach Police in 2005-2006 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 aimant, until he was arrested o 5, 2019 9. NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, Clly, Slala, and Zip Code). * None. BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED, (See instructions on reverse skie). None. STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF 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 Snjoyment of life, flashbacks, need for future medical and psychiatric expenses, and other severe injuries. \ ADDRESS (Number, Street, City, Stale, and Zip Code) 12. (See instructions on mverse). AMOUNT OF CLAIM (in dollars) 12d, TOTAL (Failure to specify may cause forfeiture of your rights), 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). 130. PHONE NUMBER OF PERSON SIGNING FORM | 14. DATE OF SIGNATURE 02/09/2024 CIVIL PENALTY FOR PRESENTING CRIMINAL PENALTY FOR PRESENTING . FRAUDULENT CLAIM CLAIM OR MAKING FALSE STATEMENTS The claimant is Bable to the United States Government for a civil panatly of not fess than Fine, imprisonment, or both, (See 18 U.S.C. 287, 100.) $5,000 and not more than $10,000, plus 3 times the amount of damages sustainad 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 Edilion is not Usable PRESCRIBED BY DEPT. OF JUSTICE 95-109 28 CFR 14.2 EFTA00155075

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In orcier that subrogation claims may bo adjudicated, It ls essential that the claimant provide the following information regarding the insurance coverage of Ihe vehicle or property, 15. Do you camy accident Insurance? () vos Hf yos, give name and address of insurance company (Number, Streat, City, State, and Zip Code) and policy number. [x] No 19. Do you carry public liability and property damage Insurance? [| Yes tyes, give name and address of insurance carter (Number, Street, City, Stale, and Zip Code). XI 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. ACLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL two ypars from the date the claim sccrued may render your claim Invaild. A claim ig deemed presented when It is recaived by the appropriate agency, not when itis maljed. if instruction is needed in completing this form, the agency listed In item #1 on the reverse skie may be contacted. Completa regulations pertaining to claims asserted under the Federal Tort Claims Act can be found In Title 28, Code of Federal Regulations, Part 14. (Many agencies have published supplementing regulations. if more than one agency Is involved, please state each agency. The claim may be filled by a duly authorized agent or other legal representative, provided evidence satisfactory to the Government is submitiad with the claim estabishing express ‘authority to act for the claimant. A claim presented by an agent or legal representative must be presented in the name of the claimant. Mf the claim Is signed by the agent or lagal representative, it must show the title or legal capacity of the person signing and be accompanied by evidence of his/her authority to present a claim on behalf of he claimant as agont, executor, administrator, parent, guardian or other representative, Vf claimant intends to file for both personat injury and property damage, the emount for each must be shown in Rem number 12 of this form, The amount claimed should be substantiated by competent evidence as follows: (a) In support of the claim for personal injury or death, the claimant should submit ¢ written report by the altending physician, showing the nature and extent of the injury, the halure and extent of treatment, the degree of permanent disability, if any, the prognosis, and the period of hospitalization, or iIncapacttation, atiaching temized bils for medical, hospital, or burial expenses actually incurred. >) in support of claims for damage to property, which has been or can be economically repaired, the claimant should submit at least two Remizod signed stalements or estimates by reliable, disinterested concems, or, if payment has been made, tho itemized signed receipts evidencing payment. fc) In support of claims for damage to property which is not repairable, or if tha property is fost or destroyed, the claimant should submit statements as to the original cost of the property, the date of purchase, and the value of the proparty, both before and after the accident. Such statements should be by disintorosted competent persons, preferably reputable dealers or officia's famittar wilh tho type of property damaged, or by two or more competitive bidders, and should be certified as being just and comect. @ Falture to specify a sum certain will render your claim invalid and may result In forfeiture of your rights. PRIVACY ACT NOTICE This Notice Is provided in accordance wilh the Privacy Act, 6 U.S.C. 5S2a(0)(3), and concems the Information requested in the letter to which this Notice is attached. ‘A, Authority: The raquested information is solicited pursuant to ane or more of the folowing: 5 U.S.C, 301, 28 U.S.C, 501 el 869,, 28 U.S.C. 2871 ot seq. 28 C.F.R. Pant 14. Principal Purpose: The Information requested is to be used In evaluating claims. » Routine Use: See the Notices of Systems of Records for the agency to whom you are ‘submitting this form for this information, ©. Effect of Faituro fo Respond: Disclosure is voluntary. Howover, failure to supply the requested information or to execute the form may render your claim "kwalid.” This notice is sally for the purpose of the Paperwork Reduction Act, 44 U.S.C, 3501. Public reporting burden for this collection of informatian is estimated to average 6 hours per response, including the me for reviewing instructions, searching existing data sources, gathering infoernation, and maintaining the data noaded, and completing and reviewing ‘Send comments regarding this burden estimate or any other aspect of this collection of Information, including suggestions for reducing this burden, to the Director, Torts Branch, Atlenlion: Paperwork Reduction Staff, Civi Division, U.S. Department of Justice, form(s) to these addresses. Washington, DC 20530 of {o the Office of Management and Budget. Do not mail completed STANDARD FORM 95 REV. (2/2007) BACK EFTA00155076

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Final SF95-07a Final Audit Report 2024-02-09 Created: 2024-02-09 Status: Signed Transaction ID: CBJCHBCAABAASIEI4020GinOMAeZpitzqHoTaHuA6LaF "GB Final SF95-07a" History #3 Document created by Kamelle Delfin 2024-02-09 - 6:06:13 PM GMT- IP address: E% Document emailed to i sss for signature 2024-02-09 - 6:06:18 PM GMT ©) Email viewed by 2024-02-09 - 6:19:21 PM GMT- IP addre: @~ Document e-signed by || || Signature Date: 2024-02-09 - 6:22:57 PM GMT - Time Sourca: server- IP address: ma @ Agreement completed. 2024-02-09 - 6:22:57 PM GMT EFTA00155077