Information Collection

Claim for Damage Injury or Death

IC 11731 under ICR 200612-1105-002 · OMB 1105-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0008 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CIV-SF-95 Claim for Damage Injury or Death	Form
CIV-SF-95 Claim for Damage, Injury, or Death SF-95 11 17 2006.pdf www.usdoj.gov/civil/forms/forms.htm	Form

IC Title:

Claim for Damage Injury or Death

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CIV-SF-95	Claim for Damage, Injury, or Death	SF-95 11 17 2006.pdf	http://www.usdoj.gov/civil/forms/forms.htm	No		Fillable Printable

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	400,000	-2,600,000	3,000,000
Annual IC Time Burden (Hours)	2,400,000	600,000	1,800,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.