DX AF-13_Redacted [DOJ-OGR-00015171—DOJ-OGR-00015172]

| oe Claim ID: EPSTEIN VCP Epstein Victims’ Compensation Program For Victims-Survivors of Sexual Abuse by Jeffrey Epstein ATTESTATIONS/SIGNATURE PACE (For Submission of Wet Signature) This portion of the Claim Form must be signed and notarized. The Epstein Victims’ Compensation Program cannot begin processing your claim until this form is submitted with the Claimant’s original signature and a notary Signature and seal. I hereby certify that the information provided in this Claim Form and any documents provided in support of this claim are true and accurate to the best of my knowledge, and declare under penalty of perjury that the foregoing is true and correct. I understand that false statemenis or claims made in connection with this claim may result in fines, imprisonment and/or any other remedy available by law, and thai claims that appear to be potentially fraudulent or to contain information known to me to be false when made will be forwarded io federal, state and local law enforcement authorities for possible investigation and prosecution. I authorize the Administrator of the Epstein. Victims’ Compensation Program and her designees to use and/or disclose information submitted as part of my claim for the purposes of processing and evaluating my claim, adminisiering the Program and other Program-relaied work, such as the resolution of applicable Medicare and/or Medicaid liens, and reports to law enforcement where appropriate. Note: The claim file is not availiable for inspection, review, or copying by the Estate, the Claimant or the Claimani’s representatives. I agree that by participating in the Program, I am using the services of a third-party administrator to help reach a resolution, of my claim, and that the Program is entiiled to confidentiality and protection from disclosure under applicable laws, For Claimanis with an attorney or other authorized representative, the claimant and the attorney or other authorized represeniative must initial in acknowledgement of the following: I acknowledge that the attorney or other authorized representative nufed herein is authorized to act on my behalf. I further authorize the Administrator of the Epstein Victims’ Compensation Program, her designees and contractors assisting in the administration of the Program to contact and communicate with my attorney or other persons authorized to act on my behalf. lof2 Epstein Victims’ Componsetion Program Attn: Jordana H. Feldman, Administrator 1050 Connecticut. Ave. NW #65488 Washington, D.C. 20035 12 DOJ-OGR-00015171