Number range CHAPTER **AWARD DETERMINATION PERIODIC PAYMENT AGREEMENT**

In accordance with Title IV of the Air Transportation Safety and System
Stabilization Act, the Special Master of the September 11^th^ Victim
Compensation Fund (the "Fund") has determined the award for claim no.
1234 for the death of JOHN DOE pursuant to the authority vested in him.
This award shall be made subject to the terms and conditions stated
below.

**Terms and Conditions**

1.  The award for this claim is:

    a.  A single payment in the amount of ONE MILLION DOLLARS AND NO
        CENTS (\$1,000,000.00) paid to the account of JANE DOE; and

        b\. \"Eight hundred periodic payments, each in the amount

        of ONE THOUSAND DOLLARS AND NO CENTS (\$1,000.00), paid to the
        account of PATRICK DOE (\"payee\"). The first payment shall be
        made on July 1, 2003. The remaining payments shall be made on a
        monthly basis thereafter.

        If a payee dies before the payment of the last periodic payment
        to which that payee is entitled, all remaining payments shall be
        made payable in accordance with a written designation of
        successor payee(s) signed by that payee, provided that any such
        designation shall be in a form acceptable to the payor and shall
        be sent to the payor prior to the payee\'s death. If at the time
        of the payee\'s death there is no valid designation in effect,
        or if none of the designated successor payees survive the payee,
        then all remaining payments shall instead be made payable as
        follows: if the payee was a minor, then to the payee\'s parents
        in equal shares (or all to the survivor of them); or, if neither
        parent of a minor payee survives the payee, or if the payee was
        an adult, then to the Estate of the payee.

        c\. The sum of ONE THOUSAND DOLLARS AND NO CENTS (\$1,000.00)
        per month to SUSAN DOE, commencing on July 1, 2003, for life.

        2\. The United States of America ("United States") hereby
        assigns the obligation to make the periodic payments described
        in paragraphs 1(b) and 1(c) above ("Paras. 1(b) and 1(c)") to
        the ABC Assignment Company ("ABC"). ABC hereby assumes this
        obligation pursuant to the terms and conditions set forth in
        this Award Determination Periodic Payment Agreement. ABC's
        obligation to make the periodic payments described in Paras.
        1(b) and 1(c) is equal to the obligation of the United States
        prior to the assignment.

        3\. In exchange for assuming the obligation to make the periodic
        payments described in Paras. 1(b) and 1(c), ABC shall receive a
        payment from the United States Treasury in the amount of FOUR
        HUNDRED THOUSAND DOLLARS AND NO CENTS (\$400,000.00).

        4\. The periodic payments in Paras. 1(b) and 1(c) cannot be
        accelerated, deferred, increased or decreased by PATRICK DOE or
        SUSAN DOE or any payee or beneficiary; nor shall PATRICK DOE or
        SUSAN DOE or any payee or beneficiary have the right or power to
        transfer, by sale, gift, or otherwise, mortgage, encumber, or
        anticipate the periodic payments, or any

        part thereof, by assignment or otherwise. However, nothing in
        the prior sentence shall be deemed to prevent transfers in
        distribution of the interest in the periodic payments by reason
        of the death of the payee. The obligation of ABC to make the
        periodic payments described in Paras. 1(b) and 1(c) shall be
        discharged upon the mailing of valid checks in the amounts of
        such payments to the designated addresses of the payees named
        above. Each payee shall be responsible for maintaining a current
        mailing address with ABC.

        5\. ABC may fund its obligation to make the periodic payments
        described in Paras. 1(b) and 1(c) through the purchase of
        annuity contracts that comply in all respects with the
        requirements of 26 U.S.C. §130(d) for a "qualified funding
        asset," provided that any such annuity contract is issued by a
        life insurance company that:

        is licensed to do business as an insurance company under the
        laws of any State;

        has a minimum of \$100,000,000 capital and surplus, exclusive of
        any mandatory security valuation reserve; and

        has one of the following "Financial Strength Rating" scores from
        two of the following rating organizations - A.M. Best Company
        (A+, A+g, A+p, A+r, A+s, A++, A++g, A++p, A++r, or A++s),
        Moody's Investor Service (Aa3, Aa2, Aa1, or Aaa), Standard and
        Poor's (AA-, AA, AA+, or AAA), or Fitch (AA-, AA, AA+, or AAA).

6\. All rights of control in any annuity contract purchased pursuant to
paragraph 5 above ("Para. 5") shall be and remain vested in ABC
exclusively. The rights of PATRICK DOE, SUSAN DOE, or any payee or
beneficiary, against ABC shall be no greater than the rights of a
general creditor.

7\. ABC may have the issuer of any annuity contract purchased pursuant
to Para. 5 send any payments under that annuity contract directly to the
payees designated pursuant to Paras. 1(b) and 1(c). Such direction of
payments shall be solely for ABC's convenience and shall not provide
PATRICK DOE or SUSAN DOE or any other payee or beneficiary, with any
rights of ownership or control over any such annuity contract or against
the issuer of such a contract.

8\. JANE DOE, PATRICK DOE, and SUSAN DOE understand and agree that, as a
consequence of ABC's assumption of the liability to make the periodic
payments in Paras. 1(b) and 1(c):

a\. the obligation to make the periodic payments described in Paras.
1(b) and 1(c) shall belong solely and exclusively to ABC;

b\. the United States does not guarantee or insure any of the periodic
payments described in Paras. 1(b) and 1(c); and

c\. the United States does not guarantee or insure any payments under
any annuity contract purchased to fund the periodic payments described
Paras. 1(b) and 1(c).

9\. JANE DOE, PATRICK DOE, and SUSAN DOE further understand and agree
that, as a consequence of ABC's assumption of the liability to make the
periodic payments in Paras. 1(b) and 1(c), neither they, nor their
successors-in-interest, shall have any rights against the United States
in the event of a default by either (1) ABC on any of its obligations
under this Award Determination Periodic Payment Agreement, or (2) the
issuer of any annuity contract purchased pursuant to Para. 5 on any of
its obligations under such an annuity contract. JANE DOE, PATRICK DOE,
and SUSAN DOE also understand and agree that upon the execution of this
Award Determination Periodic Payment Agreement by all parties, the sole
obligation of the United States under this Award Determination Periodic
Payment Agreement shall be to make the payments described in Para. 1(a)
and paragraph 3 above ("Para. 3\").

10\. JANE DOE, PATRICK DOE, and SUSAN DOE hereby consent to and accept
ABC's assumption of all liability for the periodic payments described in
Paras. 1(b) and 1(c). JANE DOE, PATRICK DOE, and SUSAN DOE hereby agree
that, once the payments described in Para. 1(a) and Para. 3 have been
made, the United States shall be released from all obligations
associated with this claim for the death of JOHN DOE, including but not
limited to the obligation to make the periodic payments described in
Paras. 1(b) and 1(c). Should ABC, or its successor-in-interest, refuse
to accept the payment described in Para. 3, this Award Determination
Periodic Payment Agreement shall be void.

11\. The terms and conditions in this Award Determination Periodic
Payment Agreement must be accepted in their entirety and without
reservation by JANE DOE, PATRICK DOE, SUSAN DOE and ABC (the "Parties").
An executed copy of this Award Determination Periodic Payment Agreement
bearing the signatures of each of the Parties must be received by the
Office of the Special Master no later than **(insert date two weeks
hence)**. If an executed copy of this Award Determination Periodic
Payment Agreement is not received by the above deadline, this Award
Determination Periodic Payment Agreement shall be void.

The undersigned Parties hereby accept and agree to abide by the above
stated terms and conditions of this Award Determination Periodic Payment
Agreement. The Parties acknowledge that this document contains the
entire agreement between themselves and the United States. The Parties
agree that they each have had a full and fair opportunity to consult
with an attorney regarding the advisability of accepting the terms and
conditions of this Award Determination Periodic Payment Agreement. The
Parties agree that their acceptance of the terms and conditions of this
Award Determination Periodic Payment Agreement has been made without
reliance upon any statements by the United States, its attorneys,
agents, employees or agencies. The parties specifically understand and
agree that (1) the United States makes no representations regarding the
tax consequences of accepting the terms and conditions of this Award
Determination Periodic Payment Agreement and (2) that the United States
makes no representation regarding whether this Award Determination
Periodic Payment Agreement conforms to the requirements of Revenue
Ruling 2003-115.

The Parties hereby waive any claim they may now have, or may hereafter
acquire, against the United States, its agencies, and its present or
former agents or employees, for any tax liability the Parties may incur
as a result of, in any way relating to, their acceptance of the terms
and conditions of this Award Determination Periodic Payment Agreement.

JANE DOE

PATRICK DOE

SUSAN DOE

Authorized Representative of

ABC ASSIGNMENT COMPANY

(All of the above signatures must be notarized)

For the United States of America

KENNETH R. FEINBERG

Special Master