Form 95 - Claim For Damage, Injury, Or Death 2007
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1
2INSTRUCTIONS:
FORM APPROVED
CLAIM FOR DAMAGE,
Please read carefully the instructions on the
OMB NO. 1105-0008
reverse side and supply information requested on both sides of this
INJURY, OR DEATH
form. Use additional sheet(s) if necessary. See reverse side for
additional instructions.
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 EMPLOYMENT
4. DATE OF BIRTH
5. MARITAL STATUS
6. DATE AND DAY OF ACCIDENT
7. TIME (A.M. OR P.M.)
MILITARY
CIVILIAN
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 THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED.
(See instructions on reverse side).
PERSONAL INJURY/WRONGFUL DEATH
10.
STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE THE NAME
OF THE INJURED PERSON OR DECEDENT.
WITNESSES
11.
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 INCIDENT 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 PERSON SIGNING FORM 14. DATE OF SIGNATURE
CIVIL PENALTY FOR PRESENTING
CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
FRAUDULENT CLAIM
CLAIM OR MAKING FALSE STATEMENTS
The claimant is liable to the United States Government for a civil penalty of not less than
Fine, imprisonment, or both. (See 18 U.S.C. 287, 1001.)
$5,000 and not more than $10,000, plus 3 times the amount of damages sustained
by the Government. (See 31 U.S.C. 3729).
NSN 7540-00-634-4046
STANDARD FORM 95 (REV. 2/2007)
Authorized for Local Reproduction
PRESCRIBED BY DEPT. OF JUSTICE
Previous Edition is not Usable
28 CFR 14.2
95-109
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