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 ocamence and the cause thereof. Use additional pages if necessary). See Addendum 9. PROPERTY DAMAGE NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City. State. aid Lc, Code). N/A BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED. (See instructions on reverse side). N/A 10. PERSONAL INJURY/WRONGFUL DEATH STATE THE NATURE AND 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. This claim is on behalf of and as well as all other Epstein victims trafficked in the Epstein sex trafficking conspiracy after August 29, 1996. As a result of negligent failures, acts and omissions detailed in the Addendum, Mses. and along with many other victims have suffered from the Epstein sex trafficking conspiracy. 11. WITNESSES NAME ADDRESS (Number. Street, City. State. and La Code) See Addendum 12. (See