SF 95 Supporting Statement Jan 2009

SUPPORTING STATEMENT
Part A. Justification:
1. Necessity of Information Collection:
A lawsuit against the United States Government may be brought under the Federal Tort Claims
Act only if the plaintiff has first sought administrative claim relief from the appropriate Federal
agency involved. The claim must be presented in writing, and this requirement can be satisfied
by utilizing the Claim for Damage, Injury, or Death Form (Standard Form 95 or SF 95). 28
U.S.C. § 2672, et seq. and 28 C.F.R. Part 14 authorize the use of the Claim for Damage, Injury,
or Death Form (SF 95) to carry out the provisions of 28 U.S.C. § 2675.
The identifiable information included on this form is the name, address, date of birth, telephone
number, marital status, and type of employment of the claimant.
The Claim for Damage, Injury, or Death Form (SF 95) has not been altered in any way since the
last OMB approval. The annual burden estimate has remained the same.
2. Needs and Uses:
The Claim for Damage, Injury, or Death Form (SF 95) is used by persons, businesses, or State,
Local or Tribal Governments presenting administrative tort claims under the Federal Tort Claims
Act, 28 U.S.C. § 2671, et seq. on a case-by-case basis. The information provided on the Claim
for Damage, Injury, or Death Form (SF 95), including the identifiable information, is necessary
for the Federal agency to investigate and evaluate the claim. The information is shared only with
the appropriate personnel within the Federal agency. Agencies are tasked with investigating
these claims to ensure that justified claims are resolved.
3. Information Technology
The Claim for Damage, Injury, or Death Form (SF 95) is available electronically. It can be
obtained through the Civil Division’s web site (http://www.usdoj.gov/civil/home.html) or
through the U.S. Government’s forms web site (http://www.forms.gov). However, it was
decided not to automate this form. Submitted claims can require extensive supporting
documentation that generally cannot be supplied electronically (for example, estimates for
property damage, medical records/bills, employment/wage certification, death certificates and
tax returns). Allowing part of the submission to take place electronically, with hard copy,
supporting documentation to follow, would result in a fragmented process. In addition, some
individuals may never send the follow-up information which would leave Federal agencies with
open claims that could not be reconciled.
4. Efforts to Identify Duplication:
The Claim for Damage, Injury, or Death Form (SF 95) is unique in that it is the only form that
captures the information required to process a claim under the Federal Tort Claims Act.

5. Methods to Minimize Burden on Small Entities:
The Claim for Damage, Injury, or Death Form (SF 95) does not impact small businesses or other
small entities. Its impact is primarily on the individual. The Civil Division has minimized the
information required to complete the form so as to minimize the burden placed on the public.
Only essential data is required to process a claim. Additionally, individuals need only make one
written submission to file a claim under the Federal Tort Claims Act.
6. Consequences of Less Frequent Collection:
The program could not be effectively implemented without the Claim for Damage, Injury, or
Death Form (SF 95). Without standardization of key information to process the claim, resources
would be expended on non-productive data collection.
7. Special Circumstances Influencing Collection:
There are no special circumstances that would cause an information collection to be conducted in
any unusual manner.
8. Federal Register/Consultations:
A 60 day notice has been published in the Federal Register (73 FR 65883). A 30 day notice has
been published in the Federal Register (74 FR 921).
9. Payment/Gift to Claimant:
The Civil Division does not provide payments or gifts to respondents.
10. Assurance of Confidentiality:
Information collected is in accordance with the Privacy Act, 5 U.S.C. § 552a(e)(3). The reverse
side of the Claim for Damage, Injury, or Death Form (SF 95), under the Privacy Act Notice, Item
D, states that disclosure of the information collected through the SF 95 is voluntary. The
authority to request the information is solicited pursuant to one or more of the following:
5 U.S.C. § 301 (General statutory authority for development and review of regulations relating to
Department of Justice matters), 28 U.S.C.§ 501 et seq. (Legal authority to collect information),
28 U.S.C. § 2671 (Tort Claims Procedures), and 28 C.F.R. Part 14 (Department of Justice
regulations governing claims asserted under the Federal Tort Claims Act).
11. Justification for Sensitive Questions:
The Claim for Damage, Injury, or Death Form (SF 95) does not ask any questions of a sensitive
nature.
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12. Estimate of Hour Burden:
This collection totals 600,000 burden hours annually. Each respondent will take six hours to
complete and present the Claim for Damage, Injury, or Death Form (SF 95). Since there are
approximately 100,000 annual respondents, there will be a total of 600,000 burden hours
annually.
The estimated total annual cost burden to respondents resulting from the collection of
information is $6,000,000. This was obtained by multiplying the 600,000 burden hours by $10
per hour. (600,000 hours x $10/hour = $6,000,000).
13. Estimate of Cost Burden:
The Civil Division of the United States Department of Justice cannot estimate the annual cost
burden to collect the information. The Department of Justice has no way of estimating the
annual record keeping hours burden because of the multitude of variables within the control of
those that file claims.
14. Estimated Annualized Cost to Federal Government:
Annualized costs to the Federal government:
$ 521,845
Salary:
Printing:
$ 22,329
Postage:
$ 5,582
Other Overhead:
$ 111,645
Total Costs:
$603,750.00
15. Program Changes:
The estimate of the cost burden in question 12 remains the same. The estimated annualized cost
to the Federal government in question 14 has increased slightly due to normal, annual increases
in the cost of services.
16. Publication:
This information collection will not result in the publication of any document.
17. Expiration Date Approval:
The Civil Division is seeking approval to not display the expiration date on the Claim for
Damage, Injury, or Death Form (SF 95). An expiration date on the form will result in
unnecessary confusion for the respondent.
18. Exceptions to Certification Statement:
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There are no exceptions to the certification statement.
Part B. Statistical Methods.
This information collection does not require the employment of statistical methods.

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