Employee Claim For Loss Of Or Damage To Personal Property
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1EMPLOYEE CLAIM FOR LOSS OF OR DAMAGE TO PERSONAL PROPERTY
NOTE: Complete and submit this form, along with supporting documents, to the Regional Counsel's office for claims in excess of $2,500.
PRIVACY ACT INFORMATION: Solicitation of the information is authorized by the Federal Military Personnel and Civilian Claims Act of
1964,31 U.S.C. §3701, et seq, as amended. Disclosure of this information by you is voluntary. The information will be used for filing a claim for
loss of or damage to employee personal property. This information will be transferred to appropriate Federal, State, local, or foreign agencies,
when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in
connection with the hiring or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a
contract, or the issuance of a license, grant, or other benefit. Failure to furnish this information will delay or prevent processing of your claim.
1. NAME OF CLAIMANT
2a. AREA CODE 2b. PHONE NO.
2c. EXT.
3. DATE OF LOSS OR DAMAGE
4a. STREET ADDRESS
5. SERVICE OR STAFF OFFICE
4b. CITY
4b. STATE
4c. ZIP CODE
6. DIVISION OR BRANCH
7. LOCATION OF LOSS OR DAMAGE
8. TOTAL AMOUNT OF CLAIM
9. DESCRIPTION OF PROPERTY (Use additional sheet, if necessary)
VALUE WHEN
PURCHASE PRICE
ESTIMATED REPAIR
DATE
OR VALUE
LOST OR
OR REPLACEMENT
ITEMIZED LISTING
ACQUIRED
DAMAGED
COST
WHEN ACQUIRED
(a)
(b)
(d)
(e)
(c)
10. TYPE OF CLAIM
c. BRIEF STATEMENT OF CIRCUMSTANCES
a. LOSS
b. DAMAGE
11. WAS PROPERTY INSURED
IF "YES", CHECKED, GIVE THE FOLLOWING INFORMATION:
a. YES
NAME OF INSURER
ITEMIZE AMOUNT COLLECTED
b. NO
CRIMINAL PENALTY FOR PRESENTING A 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)
CIVIL PENALTY FOR PRESENTING A FRAUDULENT CLAIM: The claimant shall forfeit and pay to the United States the sum of not less
than $5,000 and not more than $10,000, plus not less than double the amount of damages which the Government sustained (see 31
U.S.C. § 3729).
CERTIFICATION
I certify that I make this claim with full knowledge of the penalties for wilfully making a false claim and that I am entitled to any payments.
12a. SIGNATURE OF CLAIMANT
12b. DATE
IN WITNESS of the above claim, I on behalf of the claimant, do hereby certify that this claim is being made with full knowledge of the
penalties for wilfully making a false claim.
13a. SIGNATURE OF OTHER CLAIMANT
13b. NAME OF OTHER CLAIMANT
13d. DATE
13c. RELATIONSHIP (If any)
GENERAL SERVICES ADMINISTRATION
GSA
2116
FORM
(REV. 7/2002)
Prescribed by ADM 6200.3B
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