File a Sexual Abuse Claim

This Sexual Abuse Survivor Proof of Claim must be received no later than 5:00 p.m. (Central Time) on March 1, 2021. Please carefully read the instructions for this SEXUAL ABUSE SURVIVOR PROOF OF CLAIM and complete all applicable questions to the extent of your knowledge or recollection.

If you do not know the answer to an open-ended question, you can write “I don’t recall” or “I don’t know.” If a question does not apply, please write “N/A.”

PART 1: CONFIDENTIALITY

Unless you indicate below, your identity and your Sexual Abuse Survivor Proof of Claim will be kept confidential, under seal, and outside the public record. However, information in this Sexual Abuse Survivor Proof of Claim will be confidentially provided, pursuant to Court-approved guidelines, to the Debtor, the Debtor’s counsel, certain insurers of the Archdiocese including authorized claims administrators of such insurers and their reinsurers and counsel, attorneys for the Official Creditors’ Committee and members of the Official Creditors’ Committee, attorneys at the Office of the United States Trustee for the Eastern District of Louisiana, any unknown claims representative appointed in the bankruptcy case, any special arbitrator, mediator, or claims reviewer appointed to review and resolve Sexual Abuse Survivor Proof of Claims, any trustee, or functional equivalent thereof, appointed to administer payments to holders of Sexual Abuse Survivor Proof of Claims, and confidentially to such other persons that the Court determines need the information in order to evaluate the claim. Information in this Sexual Abuse Survivor Proof of Claim may be required to be disclosed to governmental authorities under mandatory reporting laws in many jurisdictions.

This Sexual Abuse Survivor Proof of Claim (along with any accompanying exhibits and attachments) will be maintained as confidential unless you expressly request that it be publicly available by checking the “public” box and signing below.

PUBLIC: I want my identity and this Sexual Abuse Survivor Proof of Claim (together with any exhibits and attachments) to be made part of the official claims register in this case. My claim will be available for review by any and all members of the public.

Signature (print full name)

PART 2: IDENTIFYING INFORMATION

A. Identity of Sexual Abuse Survivor

First Name

Middle Initial

Last Name

Jr/Sr/III

Mailing Address (If Sexual Abuse Survivor 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).

Number and Street

City

State

Zip Code

Country (not USA)

Telephone (Home)

Telephone (Cell)

For communications regarding this claim you may use

Check the appropriate box

US Mail

Home Voicemail

Cell Voicemail

Counsel listed below

Birthdate of Sexual Abuse Survivor (only the month and year)

Select month

Enter birth year

Social Security Number of Sexual Abuse Survivor (last four digits only)

If the Sexual Abuse Survivor is in jail or prison, provide the Sexual Abuse Survivor’s identification number

Any other name, or names, by which the Sexual Abuse Survivor has ever been known

Gender of Sexual Abuse Survivor

Male

Female

Other gender (specify)

B. If you have hired an attorney relating to the sexual abuse described in this Sexual Abuse Survivor Proof of Claim, please provide his or her name and contact information

I hired an attorney relating to the sexual abuse described in this Sexual Abuse Survivor Proof of Claim

Law Firm Name

Attorney’s Name

Number and Street

City

State

Zip Code

Country (not USA)

Telephone (Work)

Fax No.

PART 3: NATURE OF THE SEXUAL ABUSE

(Attach additional sheets if necessary)

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 sexual 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.

Please answer each of the following questions as best you are able. If you do not know or recall an answer, you may indicate that you do not know or recall the answer and move on to the next question.

A. Were you sexually abused by more than one person?

Yes

B. Please identify each person who sexually abused you. If you do not remember the name of the sexual abuser(s), provide as much information about the individual that you recall and their relationship to the Archdiocese.

C. What was the sexual abuser’s position, title, or relationship to you (if you know)

D. Where were you at the time you were sexually abused? Please be specific and provide all relevant information that you recall including the City and State, name of the religious Parish, or School, or Orphanage (if applicable) and/or the name of any other locations.

E. When did the first act of sexual abuse take place? If you do not remember the calendar date, approximately what season of the year was it (spring, summer, fall, winter), approximately what age were you when it started, and, if applicable, what school grade were you in at the time?

F. If the sexual abuse took place over a period of time, please state when it started and when it stopped. If you were sexually abused by more than one sexual abuser, indicate when the sexual abuse by each of the sexual abusers started and stopped. You may provide approximate dates if you do not recall the specific dates.

G. Please describe the sexual abuse in as much detail as you can recall in the lines below. You may attach additional pages if needed.

H. Did you or anyone on your behalf tell anyone involved with the Archdiocese about the sexual abuse?

Yes

I. Have you ever reported the sexual abuse to law enforcement or investigators? This includes telling someone when you were a minor or when you were an adult.

Yes

J. Are you aware of anyone who knew about the sexual abuse?

Yes

If your answer is “Yes”, can you describe who they were and how they knew about the abuse?

K. If subsequent wrongful conduct by the Archdiocese or its employees or officials caused you further trauma, directly or indirectly, related to the sexual abuse, please describe

a. What happened

b. When it happened

c. The name, title, position or relationship to you of any individual involved in the subsequent wrongful conduct (if you know)

PART 5: ADDITIONAL INFORMATION

A. Prior Litigation.

Was a lawsuit regarding the sexual abuse you have described in this Sexual Abuse Survivor Proof of Claim filed by you or on your behalf?

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

B. Prior Bankruptcy Claims.

Have you filed any claims in any other bankruptcy case relating to the sexual abuse you have described in this Sexual Abuse Survivor Proof of Claim?

Yes. (If “Yes,” you are required to attach a copy of any completed claim form.)

C. Settlements

Regardless of whether a complaint was ever filed against any party because of the sexual abuse, have you settled any claim relating to the sexual abuse you have described in this Sexual Abuse Survivor Proof of Claim?

Yes. (If “Yes,” please describe, including parties to the settlement. You are required to attach a copy of any settlement agreement.)

Please describe, including parties to the settlement.

D. Current Bankruptcy Case

Are you currently a debtor in a bankruptcy case?

Yes

If yes, please provide the following information

Court

Case No.

Name of Case

Date filed

Chapter of your bankruptcy case

Name of Trustee

Attachments / Documents

Necessary documentation can be attached to the Proof of Claim before the information for the form is submitted

Attachments to the Proof of Claim are required to be PDF files.

Multiple attachments to the Proof of Claim are permitted.

Click below to attach documentation (see instructions) .

Attach…

Signature

To be valid, this Sexual Abuse Survivor Proof of Claim must be signed by you. If the Sexual Abuse Survivor is deceased or incapacitated, the form must be signed by the Sexual Abuse Survivor’s representative or the attorney for the Sexual Abuse Survivor’s estate. If the Sexual Abuse Survivor is a minor, the form must be signed by the Sexual Abuse Survivor’s parent or legal guardian, or the Sexual Abuse Survivor’s attorney. (Any form signed by a representative or legal guardian must attach documentation establishing such person’s authority to sign this form for the Sexual Abuse Survivor.)

Penalty for presenting a fraudulent claim is a fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152, 157 and 3571.

Check the appropriate box

I am the Sexual Abuse Survivor

I am the Sexual Abuse Survivor’s attorney, guardian, kinship (or other authorized) caretaker, executor, or authorized representative

Other (describe)

I have examined the information in this Sexual Abuse Survivor Proof of Claim and have a reasonable belief that the information is true and correct.

I declare under penalty of perjury that the foregoing statements are true and correct.

Signature (print full name)

Title

Company name

Relationship to Sexual Abuse Survivor (if not signed by Sexual Abuse Survivor)

Number and Street

City

State

Zip Code

Country (not USA)

Telephone