CLAIM FOR DAMAGE,

CLAIM FOR DAMAGE, INJURY, OR DEATH INSTRUCTIONS: Please read carefully the instructions on the reverse side and supply information requested on both sides of this form. Use additional sheet(s) if necessary. See reverse side for additional instructions. FORM APPROVED OMB NO. 1105-0008 1. Submit to Appropriate Federal Agency: FTCA Claims Administrator do General Counsel FBI Headquarters, 935 Pennsylvania Avenue, NW Washington, D.C. 20535-0001 2. Name, address of claimant. and claimant's personal representative if any. (See instructions on reverse). Number. Street. City, State and Lp code. Go Jennifer reeman, Esq. Marsh Law Firm PLLC 3. TYPE OF EMPLOYMENT 4. DATE OF BIRTH 5. MARITAL STATUS single 6. TE ANb DAY ACCIDENT summer of 1996: before and after 7. TIME (AM. OR P.M.) 0 MILITARY X CIVILIAN B. BASIS OF CLAIM (State in detail the known fads and circumstances attending the damage. injuiy. or death. identifying persons and property involved, the place of ocamen