Claim For Damage, Injury, Or Death
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1
2CLAIM FOR DAMAGE,
INJURY, OR DEATH
INSTRUCTIONS: Please read carefully the instructions on the reverse side and
supply information requested on both sides of the form. Use additional sheet(s) if
necessary. See reverse side for additional instructions.
FORM APPROVED
OMB NO.
1105-0008
1. Submit To Appropriate Federal Agency:
2. Name, Address of claimant and claimant's personal representative, if any.
(See instructions on reverse.) (Number, street, city, State and Zip Code)
3. TYPE OF EMPLOYMENTI4. DATE OF BIRTH 15. MARITAL STATUSI6. DATE AND DAY OF ACCIDENT
n
MILITARY
n
CIVILIAN
I
I
7. TIME (A.M. or P.M.)
8. Basis of Claim (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and property
involved, the place of occurrence and the cause thereof) (Use additional pages if necessary.)
9.
PROPERTY DAMAGE
NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, street, city, State, and Zip Code)
BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF DAMAGE AND THE LOCATION WHERE PROPERTY MAY BE INSPECTED. (See
instructions on reverse side.)
10.
PERSONAL INJURY/WRONGFUL DEATH
STATE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT,
STATE NAME OF INJURED PERSON OR DECEDENT.
11.
WITNESSES
NAME
ADDRESS (Number, street, city, State, and Zip Code)
12. (See instructions on reverse)
AMOUNT OF CLAIM (In dollars)
12a. PROPERTY DAMAGE
12b. PERSONAL INJURY
12c. WRONGFUL DEATH
12d . TOTAL (Failure to specify may cause
forfeiture of your rights.)
I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE ACCIDENT ABOVE AND AGREE TO ACCEPT
SAID AMOUNT IN FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM.
13a. SIGNATURE OF CLAIMANT (See instructions on reverse side.)
13b. Phone number of signatory
14. DATE OF CLAIM
CIVIL PENALTY FOR PRESENTING
FRAUDULENT CLAIM
The claimant shall forfeit and pay to the United States the sum of
$2,000 plus double the amount of damages sustained by the United
States. (See 31 U.S.C. 3729.)
CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
CLAIM OR MAKING FALSE STATEMENTS
Fine of not more than $10,000 or imprisonment for not more than 5 years
or both. (See 18 U.S.C. 287, 1001.)
95-109
NSN 7540-00-634-4046
STANDARD FORM 95 (Rev. 7-85) (EG)
Previous editions not usable.
PRESCRIBED BY DEPT. OF JUSTICE
Designed using Perform Pro, WHS/DIOR, Jun 98
28 CFR 14.2
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