INSTRUCTION reverse side and CLAIM FOR DAMAGE, INJURY, OR DEATH sition instru! form Uso adaonal sheets) I necossary. See reverse se Tor FORM APPROVED INS: Please read caretuly the insvuctons onthe (OMB NO, 1105-0008, supply information requested on both sides ofthis iors, Saari Aprons Fedor Maeno Federal Aviation Administration Office of the Chief Counsel 800 Independence Avenue SW Washington, DC 20591 (Serbsinctars on eve) Nuno” Stet Sy Stam ara 2c Michael Stumo, Nadia Milleron, and the Estate of Samya ‘Stumo (See Attachments 1 and 2) (CIO Cotchett, Pitre & McCarthy, LLP TYPE OF EUPLOWNENT eMuan [x DATE OF BIRTH [MARITAL STATO losi2er1994 Single JS |& DATE AND DAV OF ACCIDENT mE RAC ORP jos/t0/2019 ‘Sunday 8:44 AM Fr GASIS OF CLAM (Stat nda known face ae ePEuances atendng Te da the caure hee! Ure adeonal pape nessa) Please see Attachment 2 ae icy, oF eatery pores ad propery Eva. he place of azurarce are APR - 4 2019 PROPER: TY DAMAGE NAME AND ADRESS OF OWNER, IF OTHER THAN GLAMANT (Nanber, Steet Oy, is, ad Up Oo), JBREFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AN See strains on ererse 0), Presently Unknown Personal Belongings of Samya Stumo (OTHE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED jRVIWRONGFUL DEATH STATE THE NATURE AND EXTENT OF EAGH INJURY OR CAUSE OF GEATH, WHICH Jor THE INJURED PERSON OR DECEDENT Please see Attachment 2 H FORMS THE BASIS OF THE CLAW IF OTHER THAN CLAMANT, STATE THE NAME a ‘WITNESSES NAME [ADDRESS (Number, Steet Gey. Stat, and Zp Cate) Various FAA and Boeing Employees Washington, D.C., Chicago, Seattle Claimants Massachusetts (So nsvotons onus} “AMOUNT OF CLAM fn der) Tia, PROPERTY OANAGE Tab PERSONAL NTURY Jo.00 0.00 Te. WRONGFUL DEATH "RE TOTAL Fares speaty ray came ‘entre of your ig). 25,000,000 125,000,000 [CERTIFY THAT THE AMOUNT OF CLAIM COVERS GNLY DAWAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID ANOUNTIN Tia, SIGNATURE OF CLAMANT (Sea atastons on YverseHa8) 735 PHONE NUMBER GF PERSON SVGHING FRM [1 BATE OF SIGNATURE (650) 697-6000 loaioav2019 ‘ONL PENALTY FOR PRESENTING [FRAUDULENT CLAIM rn aman abe tote Und Sites Goverment ec pony of cee than 33.000 and ot mate han $10.00, pos 3 brent aunt of eamages ssied or tne Goverman (Se0 31056-5723), ‘ORMINAL PENALTY FOR PRESENTING FRAUDULENT "SLAIN OR MAKING FALSE STATEMENTS Fra inprsonment orsnh (See 18USC. 27,1001) ‘ulnoraed for Local Reproduction Previous Editon isnot Usable 96-109 NSN 7540-00-638-4046 ‘STANDARD FORM 86 (REV. 2/2007) PRESCRIBED BY DEPT. OF JUSTICEINSURANCE COVERAGE ‘nororhateopaton cain may be ajeatod ls esonta that te aiment provi tho ftiwing formato epardng the surance coverage ofthe weil or poner. 7. Oo you cary accident newance?’[_] Yeu yes, give rune and edrss of ura company (Number, Svea Oly, Sas, and Zp Coe) an ply nue. NA TE Fave you fod ecm wit ou! auranoe carr nb ralancn ards, ball Soverge 6 deducb? Cvs 17. Weadoae, ate eraunt Te NA ae a boon fod wi you Cai, wha akon has Your neue akan or roped aka wi feranco your cain? tis pecesiay Bayou aseran tate acs), +9 Doyo cay Ben and opty damage anc? [_] Vor Wes gre nana an adios of wawrencs car Wane, Set Gy, Sm od Zip Cle) NA msrRuCTION: Claims presented under the Federal Tort Claims Act should be submitted directly to jomployee(s) was Involved in the incident. Ifthe incident involves claim form. “appropriate Federal agency” whose ‘more than one claimant, each claimant should submit a separate ‘Complete all tems - Insert the word NONE where applicable. A CLAM SHALL GE OEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL AGENCY RECEWVES FROM A CLAIMANT. Hs DULY AUTHORIZED AGENT, OR LEGAL REPRESENTATIVE. AN EXECUTED STANDARO FORM 88 OR OTHER WRITTEN NOTIFIGATION OF AN INGDENT, ACCOMPANIED BY A CLAM FOR MONEY Faure to completely execute tis form orto aupply the rquested materia within {wo yar rom ta det the claim acroad may render your calm invalid, Aci I doomed prosnted when it ls ecelved by the spproprate agoncy, not whan RIS alos. insect asain completing this form, the agancy ise in tm #1 one reverse sie maybe contacted. Costes regulators praiing clas asserted ince th Fodor Tor Cais Acca be foun Ti 2, Code of Feral Regulators, Pat any apeecie hve pushes supplementing replatons. more than ove egency is Invoed louse sate each agency. ‘Te dain may be filed by aly authored agent rote legal representat, proved ‘done enter he Governments subg wih te calm establishing eros Suory wafer te csmantA claim presoted by an ape or gel ropreseriatve un be pressed nha nae he lame. Ibe ca ened bye apet or oa epreserae, t must show h We oa! capacy of te person arin and be scromprie by eviance csr auto pesent acai on behalf caimant es ager rect, adrian, pron. guaran of ober rproseraie, itlemantintands oe fx bath personal ny a prepenty damage the amount fo [esenmuatbe shown nam rnb 12 of for DAMAGES IVA UAL CERTAIN FOR IUURY TO OR LOSS OF PROPERTY. PERSONAL 'NJURY, OR DEATH ALLEGED TO FAVE OCCURRED BY REASON OF THE INCIDENT. "THE CLAM MUST BE PRESENTEO TO THE APPROPRIATE FEDERAL AGENCY WITHIN] ‘MMO YEARS AFTER THE CLAM ACCRUES. “Th amount ened shout be substantiated by compen evidence as flows (0) tn suppor to cam fx personal in ox at, th damant shoul submit a ‘writen report by e stondng psc, sowing the naure and een oe MY. ‘tise and extn of voarent Pe cgree of peranent ay, Hy. the prognos, hd te paid of hospi, or nenpectaon, atcting Henized bis fx medica. Fos rb expeves aca need (2) tn suport clans or damage fo propery. which has been can be economical ‘epcted, be daimant shoud suit attae wo fomaadgned Utena o estates Dyroale, contrsted concerns, o payment hab boon mac, fhe Nemzed signed ‘cee evidencing payment. {c) in cuppoot in fr damage to property which is not conamlety epi, of the propery lost or cosvoyes, he cman shod wb satamans a th orginal ‘oat ne propery, ai of purchase, and he vale fe propery bot Before an ‘Sore cde Sucasslments shou be by duinresed compet perons, Protrtyroputable ders or fic falar wit te ype of proper mage ory [i ormave campattve bier, and dou be cared as beg js and core (9 Fator to opacity forte of your Aah. 1m certain wl rondar your eli veld and may ret PRIVACY ACT NOTICE This Note provided in ceardanca with he Privacy Act, USC. $8248) end ‘oncom the tomaton equate in ha tro wh i Noe itched. ‘x aahory. The regursadnorratonetlted pursuant ane or mor lhe {rowing SUSE 207,28 USC. 508 o600q, 2BUSC. 2671 eheeg, CFR. inp Purpose: Te irfomaton requested ito be soda evn di Routine Use. Seo to Noss of Sytem of Records rhe agency whoo you are ‘big tis for ots wfomaton. 1. tect eFalure to Respond: Discsut voir, However, fue to sot te feuesed noma ota exe the tr may render ou a Tvl” PAPERWORK Rt JoTION ACT NOTICE ris not is oe rhe purpose fhe Paperwork Redcton Act 4 U.S.C 3601. Public rporing burn fori slacson of formation i ext o average hous pet respons, nrg pe aac cr revaning Rewvcsone seurcrgexeing Gis sours, ater and mariarng te data neaded and completing ad roving the alecson ot Hane ee a repuntyfisoursen ema ory tr aap vs easton of etornaton incrg suggestion fr rocuang Pls burn the Dect, Tos dormer Sepanton Reduston Saf Cit Drision, US. DepertnantetJusten,Weshngion DC 20830 oro be Otis ef Manapemantana Budget Donams! competed fom) tose edieses. "STANDARD FORM 95 REV. (22007) BACKATTACHMENT 1 ATTORNEY AUTHORIZATION Federal Aviation Administration Office of the Chief Counsel 800 Independence Avenue SW ‘Washington, DC 20591 We, Michael Stumo and Nadia Milleron, both individually and as parents of the decedent ‘Samya Stumo, hereby designate and authorize Frank M. Pitre of the law firm Cotchett, Pitre & McCarthy, LLP and Robert A. Clifford with Clifford Law Offices to represent our interests, and the interests of our deceased daughter Samya Stumo, and continue any and all claims which have ‘been filed or will be filed arising from the March 10, 2019 crash of Ethiopian Air Flight 302. Executed this a4 ayo the 214 at NeGeld MA 0120-7 7 ‘Signature of Michael Stumo Signature of Nadia Milleron =