Madoff Victim Fund

Filing Tips for Electronic Claims Filers

Please read the Frequently Asked Questions at www.madoffvictimfund.com in their

entirety prior to beginning your claim submission.
→ You must complete the following tabs:

General Information - Fill-in

TEMPLATE

Collateral Recovery

General Information Tab

This tab identifies the Pooled Investment Vehicle submitting the claims on behalf of its clients (the
→ "underlying investors").
→ The General Information-Example tab should be useful in completing this information.
Template Tab
The transaction data in this template should consist of the investments and withdrawals that your
→ underlying investors made with you, the pooled vehicle. All deposits/purchases/subscriptions and
withdrawals/sales/redemptions must be individually listed. Submissions that list one net total or a
percentage of a fund will be REJECTED.
You MUST put your data in the format on the Template Tab. If you do not have the data for a certain
→ column, leave that column blank. Mandatory columns are so noted. eFile claims are not considered
filed until we receive a template in the proper format.
→ DO NOT add or delete any column to/from this template.
→ DO NOT skip rows between accounts.
Column D (Internal Account Number) must be populated. New claims are created with each internal
→ account number.
→ Example data has been entered in lines 10-18. You should remove this data.

Collateral Recovery Tab

Please report any recoveries of which you are aware that the underlying investors have
received for any or all of the losses incurred as a result of their investments in Madoff
→ Securities (e.g., bankruptcy related recoveries, litigation recoveries, insurance recoveries
or recoveries from any other source).
→ Please include documentation to support any recovery they have received.
→ Example data has been entered in lines 8 and 9. You should remove this data.

Backup Documentation
Madoff Victim Fund
Filing Tips for Electronic Claims Filers

Please read the Frequently Asked Questions at www.madoffvictimfund.com in their

entirety prior to beginning your claim submission.

You must submit documentation with your Electronic Submission that supports the transactions provided
in your file. This documentation may include: statements, trade confirmations, wire transfer
→ confirmations, cancelled checks, receipts, signed letters from fund administrators or investment advisors
(on company letterhead), trade reports, etc. Printouts must be directly from your database or tracking
software. Handwritten documentation and/or personally prepared spreadsheets are not acceptable forms
of documentation but can be included as supplemental information if it helps add clarity. We reserve
the right to request additional documentation at any time after your file has been received.

You must provide documentation detailing the account relationship between the pooled investment
vehicle and the underlying indirect investors. Depending on the type of pooled investment vehicle,
documentary proof can include a copy of a partnership agreement, an operating agreement, an account
→ opening document, an investment management agreement or a trust agreement. If the documentation
governing the account relationship is the same for all of the underlying investors, a pooled investment
vehicle need only provide documentary proof of the account relationship with one claim filed on behalf
of its underlying investors. If the relationship document is unique for each investor, please provide each
such agreement.
You must submit documentary evidence of the percentage of the underlying investor's assets that were
→ ultimately invested in, or withdrawn from, Madoff Securities. This may include various tiers of
intermediaries prior to reaching a Madoff Securities account.
You must submit documentation to support any recovery payments the underlying investors have
→ received to compensate them for any portion of the losses they incurred as a result of their investment in
Madoff Securities.

Certification and Release

Please print, read and sign the PV eFile Certification and Release form available at
→ www.madoffvictimfund.com.
Each underlying investor will individually be required to provide a Certification and Release. We may
→ pre-populate claim forms (with the data and address information you provide for each investor) and mail
them directly to each underlying investor. They will be required to review the claim form, sign and
return it to MVF.

Submission
The claims filing deadline is February 28, 2014. Your submission must be postmarked by the deadline
→ in order to be considered for eligibility.
Please securely submit this completed eFile template electronically to: eFile@madoffvictimfund.com
→ or mail a CD to: Madoff Victim Fund P.O. Box 6310, Syracuse, NY 13217 Attention: MVF eFile.
→ Please mail the signed PV eFile Certification to the submission address noted above.
If the Pooled Vehicle's claim was sold, please complete and return PV Form T-1 available at
→ www.madoffvictimfund.com
Completion of this electronic claims submission does not entitle your investors to a distribution from
→ MVF. Determination letters regarding the eligibility of claims will be mailed later in the claims process.
Madoff Victim Fund
Instructions for Template Tab - Electronic Claims Filers

Column Field Instructions

You are submitting these claims on behalf of the identified investors, who are/were your
clients in the identified pooled vehicle and whose funds were transferred, in whole or in
part, to Madoff Securities (the “underlying investors”). Enter the Madoff Securities
Account Number in which the underlying investors’ funds were ultimately invested, even if
their funds passed through multiple layers of intermediaries before they were deposited at
Madoff Securities Madoff Securities.
A
Account Number
If the Pooled Vehicle transferred money of the underlying investors to more than one
Madoff Account, please file a separate eFile submission for each such Madoff Account.

Please review the graphic depiction tab. In that example, Delta Investment Fund would file
two eFile submissions: one for those underlying investors whose funds were transferred to
Epsilon Equities and then invested in Madoff Securities (depicted in white) and one for
those underlying investors whose funds were transferred first to Beta Investment Fund, then
to The Alpha Company and then invested in Madoff Securities (depicted in blue).
Madoff Securities
B
Account Name Name/Title of the Madoff Securities Account for the Account Number noted in column A.
Pooled
C Vehicle/Intermediary
Name Enter the name of the pooled vehicle submitting these claims.

Internal Account This is your internal account number or identifier for each of your underlying investors.
D Format as a text column. This column must be filled in.
Number
This column creates a separate claim for each underlying investor.

Please use the full claimant account name including FBO and similar designations if
applicable, do not abbreviate.
Account Title/
E
Claimant Name A Pooled Vehicle should not treat another pooled vehicle as an underlying investor or file a
claim on behalf of another pooled vehicle. Only individuals or entities who lost "their own
money" are potentially eligible victims. Any intermediary pooled vehicles should submit
claims for their investors.

Underlying Investor Enter the underlying investor's U.S. Taxpayer Identification Number or Social Security
F Number.
Tax ID
Do not use your Taxpayer ID.
Account/Underlying If the underlying investor does not have a U.S. TIN or SSN, but does have a foreign ID,
G
Investor Foreign ID please enter it here.
H Joint Claimant Name Full name of joint account holder (if applicable).
Joint Claimant Tax
I
ID U.S. TIN or SSN of joint account holder.
Foreign ID of joint If the underlying investor does not have a U.S.TIN or SSN, but does have a foreign ID,
J
account holder please enter it here.
K Attention If not the underlying investor, enter the name of the primary contact for the underlying
investor.
Madoff Victim Fund
Instructions for Template Tab - Electronic Claims Filers

Column Field Instructions

Columns K-T: Enter the underlying investor's last known contact information. Do not enter
L Mailing Address1 the contact or address of the pooled vehicle (that information goes on the General
Information tab).
M Mailing Address2
N City
O State
P Zip
Q Province
R Country
S E-mail Address
T Phone

Key:
CO = Corporation
LLC = Limited Liability Company
IN = Individual
JO = Joint owners
U Claim Type IRA = IRA or 401(k)
TT = Trust
ES = Estate
PT = Partnership
MF = Mutual Fund
NPO = Charitable Foundation/Non-Profit Org.
UGMA = Custodial
ERISA = Defined Benefit Pension or Health Care Plan
O = Other

Key:
DP = Deposit
V Transaction Type P = Purchase
WD = Withdrawal
S = Sale
TI = Transferred In
TO = Transferred Out
Transaction
W description or note if Use this field to add a description of the transaction that may be helpful in the claims
applicable process (e.g., if a transfer, denote where the funds were sent/came from).
X Transaction .Date Use the date of the transaction.
Y Share Quantity If the investment was made in a unitized fund, enter the number of shares purchased or
sold. Round fractional shares to four decimals.
If the investment was made in a unitized fund, enter the price per share at the time of the
Price Per Share on purchase or sale.
Z
Transaction Date
Enter a number, not a formula.
AA Currency Used Please indicate the currency used for the transaction which should match the backup
documentation.
Madoff Victim Fund
Instructions for Template Tab - Electronic Claims Filers

Column Field Instructions

Please enter the transaction total. Deposit/Purchase transactions should not include any
transaction fees that were charged. Record only the amount of money actually invested or
AB Transaction Total withdrawn.

Enter all amounts as positive numbers, the transaction type will determine whether the
amount is added or subtracted in the loss calculation. Do NOT enter negative numbers.
Madoff Victim Fund Electronic Claim
General Information for Pooled Vehicle

General Information:
Pooled Vehicle Name
Tax ID of Pooled Vehicle
Name of Receiver or Liquidator
(if applicable)
Operating status of pooled vehicle
(Operating, Closed, In Liquidation, Other)
Madoff Securities Account in which funds were ultimately
invested
ONLY ONE Madoff Account per eFile submission

Sold or Transferred Claim:

¨ Yes
(Please complete and return PV Form T-1 available at
Was the Pooled Vehicle's claim sold or transferred? www.madoffvictimfund.com)

¨ No

Conact Information for the Pooled Vehicle:

Contact Name for Claims Filer:
Street Address Line 1
Street Address Line 2
City
State
Zip
Phone Number(s)
E-mail Address

Submission Details:
Date File submitted
Submission method (mailed CD, emailed file)

Control Totals:
Aggregate Total Number of Accounts included in eFile
Aggregate Total Number of Transactions on eFile

Percentage of
Investment
Disclose any additional intermediary pooled vehicles (if Allocated to
applicable). If you placed the underlying investors funds Entity at
directly into Madoff Securities, please enter "N/A". Entity Name 12/11/2008
Did the enitity noted in column AD of the template place the
underlying investors' funds in a Madoff Securities Account or in
another pooled vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
If an intermediary vehicle, did that entity place the underlying
investors' funds in a Madoff Securities Account or in another
intermediary vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
If an intermediary vehicle, did that entity place the underlying
investors' funds in a Madoff Securities Account or in another
intermediary vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
If an intermediary vehicle, did that entity place the underlying
investors' funds in a Madoff Securities Account or in another
intermediary vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
 A B C D E F G H I
1 Madoff Victim Fund Electronic Claim Template for use by Pooled Investment Vehicles
2
3
4 Please review instructions on the INSTRUCTIONS Tab.
5
6 Mandatory Mandatory Mandatory Mandatory Mandatory

This is your internal

account number or
7 identifier for your
Client (underlying
Madoff Securities investor).
Account Number that the Format as a text
investor's funds were column. This column Account/Underlying
ultimately invested in. Name on the Madoff Identity of the Pooled must be filled in. Investor U.S. Tax ID
Securities account that Vehicle or Intermediary This column creates
ONLY ONE Madoff corresponds with the submitting these claims the claim and will Please use full name of account
Account per eFile Account Number noted in for the benefit of its appear on all including FBO designations if Do not use the Account/Underlying Full name of joint U.S. Tax ID of joint
Submission column A. underlying investors. correspondence. applicable, do not abbreviate. intermediary's Tax ID Investor Foreign ID account holder account holder
8
Pooled
9 Madoff Securities Madoff Securities Vehicle/Intermediary Internal Account Investor
Account Number Account Name Name Number Account Title/ Claimant Name Investor Tax ID Foreign ID Joint Claimant Name Joint Claimant Tax ID
10 1FN9999 The Alpha Company Delta Investment Fund 10-10133 John J. Smith 123-45-6789 Mary K. Smith 567-89-1234
11 1FN9999 The Alpha Company Delta Investment Fund 10-10133 John J. Smith 123-45-6789 Mary K. Smith 567-89-1234
12
1FN9999 The Alpha Company Delta Investment Fund 10-10133 John J. Smith 123-45-6789 Mary K. Smith 567-89-1234
13 1FN9999 The Alpha Company Delta Investment Fund 10-10133 John J. Smith 123-45-6789 Mary K. Smith 567-89-1234
14 1FN9999 The Alpha Company Delta Investment Fund 60-95111 Acme Widgets Defined Benefit Plan 20-9876543
15 1FN9999 The Alpha Company Delta Investment Fund 60-95111 Acme Widgets Defined Benefit Plan 20-9876543
16 1FN9999 The Alpha Company Delta Investment Fund 60-95111 Acme Widgets Defined Benefit Plan 20-9876543
17 1FN9999 The Alpha Company Delta Investment Fund 60-95111 Acme Widgets Defined Benefit Plan 20-9876543
18 1FN9999 The Alpha Company Delta Investment Fund 60-95111 Acme Widgets Defined Benefit Plan 20-9876543
 J K L M N O P Q R S T
1
2
3
4
5
6 Mandatory

Foreign ID of joint
account holder The underlying investor's mailing address and contact information.
8
Province
9 (Canada &
Joint Foreign ID Attention Mailing Address1 Mailing Address2 City State Zip Australia) Country E-mail Address Phone
10 John Smith 1 Maple St Kansas City MO 64101 USA jsmith@usa.com 8165551212
11 John Smith 1 Maple St Kansas City MO 64101 USA jsmith@usa.com 8165551212
12
John Smith 1 Maple St Kansas City MO 64101 USA jsmith@usa.com 8165551212
13 John Smith 1 Maple St Kansas City MO 64101 USA jsmith@usa.com 8165551212
14 George Acme 100 Acme Lane Box 6500 Chicago IL 60601 USA paul@acmewidgets.com 7735556000
15 George Acme 100 Acme Lane Box 6500 Chicago IL 60601 USA paul@acmewidgets.com 7735556000
16 George Acme 100 Acme Lane Box 6500 Chicago IL 60601 USA paul@acmewidgets.com 7735556000
17 George Acme 100 Acme Lane Box 6500 Chicago IL 60601 USA paul@acmewidgets.com 7735556000
18 George Acme 100 Acme Lane Box 6500 Chicago IL 60601 USA paul@acmewidgets.com 7735556000
 U V W X Y Z AA AB AC AD
1
2
3
4
5
6 Mandatory Mandatory Mandatory Mandatory Mandatory Mandatory Mandatory

Key:
CO = Corporation
LLC = Limited Liability
Company
IN = Individual
JO = Joint owners
IRA = IRA or 401(k)
7 TT = Trust
ES = Estate If unitized fund, Did you place the
PT = Partnership enter the price per underlying investors'
MF = Mutual Fund Key: Use this field to add a share at the time funds in a Madoff
NPO = Charitable DP = Deposit description of the If unitized fund, of the purchase or Please indicate the Securities Account or
Foundation/Non-Profit Org. P = Purchase transaction that may be number of shares sale, net of fees currency used for Percentage in another pooled
UGMA = Custodial WD = Withdrawal helpful in the claims and commissions. the transaction Enter the transaction total Allocated to vehicle? Enter either
ERISA = Defined Benefit S = Sale process (e.g., if a transfer, Round fractional which should Madoff or the "Madoff Securities" or
Pension or Health Care Plan TI = Transfer In denote where the funds shares to four Enter a number, match the backup Enter only absolute values next the name of the
O = Other TO = Transfer Out were sent/came from). Transaction Date decimals not a formula. documentation. (positive numbers). intermediary intermediary vehicle.
8

9 Transaction description or Price Per Share on

Claim Type Transaction Type note if applicable Transaction Date Share Quantity Transaction Date Currency Used Transaction Total Allocation % Allocated To
10 JO DP 4/7/1999 USD 100,000.00 75% Beta Investment Fund
11 JO DP 07/10/2001 USD 50,000.00 75% Beta Investment Fund
12 From John J. Smith
JO TI acct#20202 3/18/2004 USD 12,000.00 75% Beta Investment Fund
13 JO WD wire to BNY 6/15/2004 USD 25,000.00 75% Beta Investment Fund
14 CO DP 12/31/2004 USD 60,000.00 75% Beta Investment Fund
15 CO DP 12/31/2005 USD 125,000.00 75% Beta Investment Fund
16 CO DP 12/31/2006 USD 80,000.00 75% Beta Investment Fund
17 CO DP 12/31/2007 USD 50,000.00 75% Beta Investment Fund
18 CO WD 6/1/2008 USD 100,000.00 75% Beta Investment Fund
Madoff Victim Fund Electronic Claim - Reporting of Collateral Recovery

Please report any other recoveries of which you are aware that the underlying investors has received for any or all of the losses incurred as a result of their investments in Madoff
Securities (e.g., litigation recoveries, insurance recoveries or recoveries from any other source). Please include documentation to support any recovery they have received.
Please also list any other recoveries your investor expects to receive in the future through litigation, arbitration, insurance or otherwise.

This is your internal

account number or
identifier for the
underlying investor.
Format as a text
column. This column
must be filled in.
This column creates Collateral
the claim and will Please use full name of account Collateral Recovery
appear on all including FBO designations if Recovery Payment Source of
correspondence. applicable, do not abbreviate. Payment Date Amount Payment

Internal Account Payment 1 Payment 1 Payment 2 Payment 2 Payment 3 Payment 3 Payment 4 Payment 4
Number Account Title/ Investor Name Date Amount Payment 1 Source Date Amount Payment 2 Source Date Amount Payment 3 Source Date Amount Payment 4 Source
1st and 2nd
Interim Class Action
10-10133 John J. Smith 8/1/2009 $360.00 SIPC Advance 12/1/2012 $1,250.00 Distributions 6/1/2013 $525.00 Recovery
1st and 2nd
Interim Class Action
60-95111 Acme Widgets Defined Benefit Plan 8/1/2009 $550.00 SIPC Advance 12/1/2012 $2,200.00 Distributions 6/1/2013 $700.00 Recovery
Madoff Victim Fund Electronic Claim
General Information for Pooled Vehicle

General Information:
Pooled Vehicle Name Delta Investment Fund
Tax ID of Pooled Vehicle 55-1234567
Name of Receiver or Liquidator
(if applicable)
Operating status of pooled vehicle
(Operating, Closed, In Liquidation, Other) Operating
Madoff Securities Account in which funds were ultimately
invested
ONLY ONE Madoff Account per eFile submission 1FN9999 The Alpha Company

Conact Information for the Pooled Vehicle:

Contact Name for Claims Filer: Joseph Brown
Street Address Line 1 22 Delta Avenue
Street Address Line 2
City St. Louis
State MO
Zip 63101
Phone Number(s) 314-222-8000
E-mail Address j.brown@deltainvestments.com

Sold or Transferred Claim:

¨ Yes
(Please complete and return PV Form T-1 available at
Was the Pooled Vehicle's claim sold or transferred? www.madoffvictimfund.com)

þ No

Submission Details:
Date File submitted 10/1/2013
Submission method (mailed CD, emailed file) Mailed CD and paper backup

Control Totals:
Aggregate Total Number of Accounts included in eFile 2
Aggregate Total Number of Transactions on eFile 9

Percentage of
Investment
Disclose any additional intermediary pooled vehicles (if Allocated to
applicable). If you placed the subject investors funds Entity at
directly into Madoff Securities, please enter "N/A". Entity Name 12/11/2008
Did the enitity noted in column AD of the template place the
subject investors' funds in a Madoff Securities Account or in The Alpha Company 60%
another pooled vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
If an intermediary vehicle, did that entity place the subject
investors' funds in a Madoff Securities Account or in another Madoff Securities 100%
intermediary vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
If an intermediary vehicle, did that entity place the subject
investors' funds in a Madoff Securities Account or in another
intermediary vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
If an intermediary vehicle, did that entity place the subject
investors' funds in a Madoff Securities Account or in another
intermediary vehicle? Enter either "Madoff Securities" or the
name of the intermediary vehicle:
Madoff Victim Fund
Example of Investor Matrix

Delta investors

Delta
Investment
Fund
(75% to Beta
and 25% to
Epsilon) Beta investors
Epsilon
investors

Beta
Investment
Epsilon
Fund
Equities
(60% into
(40% into
Alpha) Alpha investors
Madoff)

The Alpha
Company
(100% into
Madoff)

Madoff Securities
Account 1FN3333
Epsilon Equities

Madoff Securities
Account 1FN9999
The Alpha Company