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Please carefully read the following instructions included with this claim form and complete ALL applicable questions to the best of your ability. If a question is inapplicable, please state “N/A.” All claim forms must be received no later than ______________.

The proof of claim form must be received by Slater Slater Schulman LLP by either:

  1. Completing this fillable form and emailing it to us at bsa@sssfirm.com; or
  2. Electronically by visiting www.__________.com; or
  3. If you are completing this form in hard copy, please type or print clearly using blue or black ink and hand deliver, U.S. Mail or courier the original claim form to:
    Slater Slater Schulman, LLP, 445
    Broad Hollow Road, Suite 419,
    Melville, New York 11747
    so that it is received before the deadline; or
1
Identifying Info
2
Background Info
3
Nature Of The Abuse
4
Impact Of Child Sexual Abuse
5
Additional Info

PART 1: Identifying Information

Mailing Address (If you are submitting this claim form on behalf of a party who is incapacitated,
is a minor, or is deceased, provide the address of the individual submitting the claim. If you are
in jail or prison, provide the address of your place of incarceration):

Social Security Number (last four digits only):
If you are in jail or prison, provide your identification number:
Date of Birth
Have you ever been legally known by any other names?
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PART 2: Background Information

I. Marital/Domestic Partner History:
a. Have you ever been married?

b. If yes, please provide the length of time you were married and provide your current marital status. If you are no longer married, please specify whether your marriage ended by divorce or by the death of your spouse. Use the text box below.

II. Education History:

a. What is your highest level of education completed or degree obtained?

b. Educational Institution:

III. Employment:

a. What is your current employment status:

III. Military Service:
a. Have you ever served in the military?
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PART 3: Nature Of The Abuse

For each of the questions listed below, please complete your answers to the best of your
recollection.


Note: if you have previously filed a lawsuit about your scouting-related abuse in state or
federal court, you may attach a copy of the complaint. If you have not filed a lawsuit, or if the
complaint does not contain all of the information requested below, you must provide the
information below to the extent of your recollection.

If you were sexually abused by more than one abuser, please separately provide the requested information for each abuser in this response.

a. Please name each person who sexually abused you in relation to your involvement in scouting. If you do not remember the name of the abuser(s), provide as much identifying information about each abuser(s) that you can recall, including their relationship to scouting (e.g., the Scoutmaster of Troop 100, another Troop member of Troop 200, etc.).

b. What was each abuser’s position, title, or relationship to you in scouting (check all that apply).

c. Where were you living at the time of the sexual abuse (city, state)?

d. What was the type of Troop you were involved with during the sexual abuse (check all that apply).

e. What was the troop number and physical location (city, state) of your troop(s) during the sexual abuse?

f. What was the name of the organization that chartered or sponsored your Troop (e.g., a religious institution, church, a school, a community center, or a civic group, etc.)?

f. What was the name of the organization that chartered or sponsored your Troop (e.g., a religious institution, church, a school, a community center, or a civic group, etc.)?

g. What was the name of the local council(s) that oversaw your Troop(s) during the sexual abuse or that oversaw any Boy Scout camp or other Scouting activity that you believe may have enabled or allowed the sexual abuse to occur?

[Note that such Local Councils are not currently parties to the bankruptcy so if you believe you may have a claim against any such Local Council you must take separate action to preserve and pursue any such claim.]

h. Where did each act of sexual abuse take place? Please be as specific as possible, including city and state and the name(s) of any camps, properties, schools, churches, or other locations. If any of the incidents occurred in the abuser’s home or automobile, please so state and also explain how the abuser used their position in Scouting or a Scouting activity to abuse you (e.g., in the abuser’s car on a ride home from Scout meetings, or in the abuser’s home during or after Scout meetings.)

Remember: If you were sexually abused by multiple abusers, please separately provide the information for each abuser in this response.

i. When did the sexual abuse occur? (If you cannot remember exact dates, please provide
approximate dates, i.e. month(s) and year(s).) If the sexual abuse or other wrongful sexual conduct took place over a period of time, please state when it started and when it stopped (months and years if possible).

Remember: If you were sexually abused by multiple abusers, please separately provide the information for each abuser in this response.

i. How old were you at the time of the sexual abuse by each abuser? (If you cannot remember exact age, please provide approximate age.)

k. Describe the sexual abuse. With respect to each act of sexual abuse, please describe the
frequency of the abuse, including the approximate number of times each act of sexual abuse occurred. Please attach additional pages if needed.

Remember: If you were sexually abused by multiple abusers, please separately provide the information for each abuser in this response.

l. Have you ever told anyone, including verbally or in writing, about the sexual abuse at any time? This includes telling someone when you were a child or when you were an adult.

m. Please state the name of each person you told and the date. (If you cannot remember exact dates, please provide approximate dates, i.e. month(s) and year(s).) Such persons may include, but are not limited to, parents; siblings; relatives; friends; adult Boy Scout leaders; representatives of the Boy Scouts of America (“BSA”); representatives of a local council; representatives of a sponsoring or chartering organization; attorneys (unrelated to this matter); psychologists, psychiatrists, social workers, counselors; and/or law enforcement authorities

n. Did anyone witness the abuse?

o. Please state the name of each person who you believe witnessed the abuse and the date. (If you cannot remember exact dates, please provide approximate dates, i.e. month(s) and year(s).)

p. Did you ever witness the abuser act inappropriately with anyone else?

q. If your answer to the previous question is “yes,” please state the name of each person who you believe may have experienced inappropriate behavior with the abuser and when. Also indicate whether we may contact that person(s). (If you cannot remember exact dates, please provide approximate dates, i.e. month(s) and year(s).).

Please note, we will never contact anyone you identify in response to this question without your express consent.

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PART 4: Impact Of Child Sexual Abuse

1. Please describe how you believe you were impacted, harmed, damaged, or injured as a result of the child sexual abuse you described above. This may include, but is not limited to, effect(s) on your mental health; emotional health; psychological health; physical health, education; employment; family relationships; romantic relationships; marriages; relationships with your children; and substance abuse.

2. Have you ever sought counseling or other mental health treatment for the impacts, harms, damages, and/or injuries described above?

Please identify the name of each person who provided you with counseling or mental health treatment, their location, the type of counseling or treatment and the estimated dates/time period of counseling or treatment.

If you were prescribed medication in connection with such counseling or mental health treatment, please list the name of the medication and how long you took that medication.

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PART 5: Additional Information

A. Prior Litigation. Was a lawsuit filed by you or on your behalf against the BSA concerning the sexual abuse described above?

(By selecting “Yes,” you are required to attach a copy of the complaint.)

Click “Choose File” below to upload your copy of the complaint. File types accepted are .pdf, .doc, .docx, and .pages.

B. Prior Settlement. Did you settle any claim(s) against the BSA concerning the sexual abuse described above?

(By selecting “Yes,” you are required to attach a copy of the settlement agreement.) 

Click “Choose File” below to upload your copy of the complaint. File types accepted are .pdf, .doc, .docx, and .pages.

C. Prior Claims. Have you filed any claims in any other bankruptcy case relating to the sexual abuse described above?

(By selecting “Yes,” you are required to attach a copy of the settlement agreement.) 

Click “Choose File” below to upload your copy of the complaint. File types accepted are .pdf, .doc, .docx, and .pages.

D. Bankruptcy. Have you ever filed for bankruptcy?

By selecting “Yes,” please provide the following information: 

Did you receive a discharge in such bankruptcy case?

SIGNATURE

Sign and print your name. If you are signing the claim on behalf of another person or an estate, print your title.

Under penalty of perjury, I declare the foregoing statements to be true and correct. Check “Yes” below to confirm.

SUBMIT
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