Merson Law, PLLC Merson Law, PLLC Peni ani ] Www.mersoniaw,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 Plaza, Washington, D.C. 20535 23rd Floor New York, New Re: Service of Standard Form 95 Dear Ma’am/Sir: me: 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, “Jerse Nem Jordan Merson fim encl: EFTA00155078

--=PAGE_BREAK=--

CLAIM FOR DAMAGE, INSTRUCTIONS: Piease read carefully the instructions on the reverse side and supply information requested on both sides of this INJURY, OR DEATH form. Use additional sheel(s) if necessary. See reverse side for additional instructions. 1. Submit to Appropriate Federal Agency: 2. Name, address of claimant, and claimant's porsonal representative if any. {See 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 8. BASIS OF CLAIM (State in detall the known facts and clre d the damage, Injury, or desth, identifying persons and property involved, the place of occurrence and the cause thereof, Use additional pages f necessary). This claim arises out of the sexual abuse suffered by Claimant AE ("Claimant’) at the hands of Jeffrey Epstein ("Epstein") as a result of the gross negligence, | acts, and/or omissions of the Federal Bureau of Investigation ("FBI"). Specifically, despite the fact that in 1996, oe to the FBI that she 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, 2 as arrested on VAS 019 9. PROPERTY DAMAGE NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code). None None. STATE THE NATURE ANO EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER 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. ADORESS (Number, Street, City, State, and Zip Code) AMOUNT OF CLAIM {in dollars) 12¢. WRONGFUL DEATH 12d. TOTAL (Failure to specify may cause forfelture of your rights). 20,000,000 FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM. 13a. SIGNATURE OF CLAIMANT (Si 13b. PHONE NUMBER OF PERSON SIGNING FORM | 14, DATE OF SIGNATURE ‘SENTING LENT CRIMINAL PENALTY FOR PRE! FRAUDUI CLAIM OR MAKING FALSE STATEMENTS The claimant ts lable to the United States Government for a civil penally of not less than Fine, imprisonmant, or both. (See 18 U.S.C. 287, 1001.) $5,000 end not more than $10,000, plus 3 times the amount of damages sustained by the Government. (See 31 U.S.C, 3729). Authorized for Local Reproduction STANDARD FORM 95 (REV. 2/2007) Previous Edition is not Usable PRESCRIBED BY DEPT. OF JUSTICE 95-109 28 CFR 14.2 EFTA00155079

--=PAGE_BREAK=--

In order that subrogation ctaims may be adjudicated, it is essential thet the claimant provide the following information regarding the insurance coverago of the vehicle or property. 15. Do you carry accident insurance? (1) Yes Mfyes, give name and addross of Insurance company (Number, Street, City, State, and Zip Code) and policy number. x) 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 ail items - insert the word NONE where applicable. ACCLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR LEGAL REPRESENTATIVE, AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR MONEY Fallure to completely execute this form or to supply the requested material within two years from the date the claim accrued may render your claim invalid. A claim is doomed presented when it Is recetved by the appropriate agency, not when It is malted. {f Instruction is needed in comploting this form, the agoncy listed In tem #1 on the reverse side may be contacted. Complete regulations pertaining to claims asserted under the Federal Tort Ctaims Act can be found in Title 28, Code of Federal Regulations, Part 14, Many agoncies have published supplementing regutations. if more than one agency is Involved, please state each agency. The claim may be filed by a duly authorized agent or other legal evidence to the authority to wct for the cialmant, A claim presented by an agent or legal representative Must be presented in the name of the claimant. if the claim is signed by the agent or legal representative, il must show the tillo or legal capacity of the perscn signing and bo accompanied by evidence of his/hor authority to present a clalm on behalf of tho caimant ‘@S agent, executor, administrator, parent, quardian or other representative. If claimant intends to file for both personal injury and property Gamage, the amount for each must be shown In item number 12 of this form. DAMAGES IN A SUM CERTAIN FOR INJURY TO OR LOSS OF PROPERTY, PERSONAL INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY REASON OF THE INCIDENT. THE CLAIM MUST BE PRESENTED TO THE APPROPRIATE FEDERAL AGENCY WITHIN’ ‘The amount claimed should be substantiated by competent evidence as follows: (2) In support of the claim for personal injury of death, the claimant should submit a ‘written report by the attending physician, showing the nature and oxtont of the injury, the nature and extent of treatment, the degree of permanent disability, if any, the prognosts, and the period of hospitalization, or incapacitation, attaching Itemized bills for medical, hospilal, or burial expenses actually incurred. foi In support of claims for damage to property, which has been or can be economically repaired, the claimant should subenit at least two Homized signed statements or estimates by reliable, disinlorosted concems, or, if paymant has been made, tho Memized signed receipts evidencing payment, (¢) In support of claims for damage to property which Is not repairable, of if the property Is lost or destroyed, tho claimant should submit statements as to the eriginal cost of the property, the date of purchase, and the value of the property, bath before and after the accident. ‘Such statements should be by disintoroated competent porsons, preferably reputable dealers or officials familiar with the type of property damaged, or by two or more competitive bidders, and should be certified as being just and correct. {a Failure to specify a sum certain will ronder your claim invalid and may result in forfeltuire of your rights. PRIVACY ACT NOTICE This Notice is provided in sccordance with the Privacy Act, § U.S.C. 552a{@)(3), and concerns the information requested in the letter to which this Notice ts attached. A. Authority: The requesied information is solicited pursuant to one or more of the fotlowing: § U.S.C. 301, 28 U.S.C. 501 et seq., 28 U.S.C. 2671 et seq., 28 CER. Part 14. 0. Effect of Falture to Respand; Disclosure Is voluntary, However, fallure to suppity the - requested information or to execute the form may render your clan “invalid.” This notice is solely for the purpose of the Paperwork Reduction Aol, 44 U.S.C. 3501. Public reporting burden for this collection of information Is estimated to average 6 hours per response, including the time for reviewing Instructions, searching axtating data sources, gathering and maintaining ihe data needed, and complating and information. Send comments regarding this burden estimate or any other aspect of this collection of information, reviewing tho collection of suggestions for reducing this burden, to the Director, Torts inctuding Branch, Aitention: Paperwork Reduction Staff, Civil Division, U.S. Department of Justice, Washington, OC 20530 of to the Office of Management and Budget. Do not mall completed form(s) to these addresses. STANDARD FORM 95 REV. (2/2007) BACK EFTA00155080

--=PAGE_BREAK=--

po final SF95-07a Final Audit Report 2024-02-12 Created: 2024-02-12 Status: Signed Transaction ID: CBJCHBCAABAAHMCBBdJOOBVBTK-x0sUL2RIDIVebFz7n GE final SF95-07a" History ©) Document created by Kamelle Delfin fF 2024-02-12 - 5:10:08 PM GMT- IP address: A 2024-02-12 - 5:10:12 PM GMT © Email viewed by as 2024-02-12 - 5:19:49 PM GMT- IP address {EE Document e-signed yi Signature Date: 2024-02-12 - 10:07:14 PM GMT - Time Source: server- IP addres @ Agreement completed. 2024-02-12 - 10:07:14 PM GMT Adobe Acrobat Sign EFTA00155081