J6 West Plaza Civil Action Form

Preliminary Information

The following information will be stored with your submission for our records but will NOT appear on the SF-95 PDF form.

Your Email Address

1. What happened to you on January 6, 2021 at the U.S. Capitol in your own words?

2. What injuries or damages were sustained on January 6, 2021 at the U.S. Capitol?

3. What time approximately did you enter and exit US Capitol grounds?

4. Did you go inside the U.S. Capitol Building? If so, approximately what time, and for how long.

Federal Tort Claims Act, Form 95

2. Name of Claimant

3. Type of Employment

Civilian

Military

4. Date of Birth

Street Address

5. Marital Status

City

State

Zip Code

8. Basis of Claim

While the claimant was protesting on January 6, 2021 at the West side of the U.S. Capitol, the Capitol Police and D.C. Metropolitan Police acting on behalf of the Capitol Police used excessive force against the claimant causing claimant physical injuries. The excessive force took the form of various munitions launched against the protesters including but not limited to: pepper balls, rubber balls or bullets some filled with Oleoresin Capsicum ("OC"), FM 303 projectiles, sting balls, flash bang, sting bomb and tear gas grenades, triple chasers,pepper spray, CS Gas and physical strikes with firsts or batons.

Add any additional facts or details (optional) below.

10. Personal Injury/ Wrongful Death

The claimant went to the U.S. Capitol to peacefully protest the presidential election. While the claimant was in the area of the West Side of the U.S. Capitol building police launched weapons referenced above and used excessive force. The claimant was struck and or exposed to the launched munitions and/or OC or CS Gas and suffered injuries as a result. The legal doctrine of equitable tolling allows the claimant to bring this claim at this time. U.S. v. Kwai Fun Wong, 575 U.S. 402 (2015).

Add any additional injury details (optional) below.

12. Amount of Claim (in dollars)

12a. Property Damage

12b. Personal Injury

12c. Wrongful Death

12d. Total

Please certify to continue.

I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM.

Phone Number

14. Date of signature