This document is a completed Claim form by family of an Iraqi citizen who died in U.S. custody. The gentleman was arrested on April 25, 2003. On November 11, 2004, the family visited him at Baghdad International Airport (BIAP) and his health was good. The family was told on Feb. 17, 2004 by the Red Cross that the father (the detainee) had died on January 31, 2004. According to reports, there were bruises on his face, wounds and signs of surgery on his head.
To: United States Arm
From: Name:
Address:
a.
A citizen and national of:
b.
A permanent resident of:
c.
Employed by:
d.
Check one ( ) An insurer ( ) Not an insurer
e.
Check one ( ) An subrogee ( ) Not an subrogee
I hereby make a claim against the United States Government for damages or
injuries caused by: (Name, Organization, Military Department, Address,
Telephone Number)
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•
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The property damaged is owned by: (If the claim is made as an agent, parent, or guardian, attach a power of attorney or other evidence of authority and fill in the form below for party sustaining the damage or injuries.)
My claim arose at: (Town) (City) (Country)
My claim arose on:
1 71
Month Day Year
•1
Give a brief statement of the accident or incident on which the claim for damages to property or for personal injury is based. (Use back of this sheet if necessary.)
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DOD-045969
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Describe nature and extent of property damage or personal injury sustained as a
result of the above incident.
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List in detail the amount of property damage and itemized expenses resulting
from the property damage or personal injury: (Attach bills and receipts, if
applicable.)
Item Amount
Total: 5 orQ (e)e) 6 ;ED
I was insured to the following extent against the damage or injuries I have
sustained:
The name and address of my insurer (if any) is:
(Name) (Address)
I claim as damages: (Indicate amount in U.S. do. llars and local currency) ex .4p._ local 0 re54.3 c9 e-)0_
S /
(Signature of Claimant)
Subscribed before me this day of . 200
(Print Name)
(Signature)
CI r, 4,JUU006
DOD-045970
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