§106.3. Eligibility for payments by the Department of Justice. — Inbound Citations

(1) A covered employee or covered dependent may apply for a HAVANA Act payment if the covered individual has sustained a qualifying injury to the brain on or after January 1, 2016. To apply for the benefit, the applicant must submit the “Eligibility Questionnaire for HAVANA Act Payments” claim form to the appropriate email address or fax number set forth in this paragraph (a). The claim form must be completed by a person eligible to file a claim under the HAVANA Act or by that person's legal guardian and must be signed by a currently certified physician as listed in § 106.3(a) of this part. The claim form must be emailed or faxed to the following address: [email protected] or fax number (202) 323-9420 (covered FBI employees and dependents) or [email protected] or fax number (202) 616-3200 (covered DOJ employees and dependents).