Form SF 95 SF 95 Claim for Damage Injury or Death

Transportation Security Administration (TSA)
Claims Management Branch
Tort Claim Package

OMB number. 1652-0039
Expires 11/30/2011

You have downloaded the Tort Claim Package for TSA. If you have suffered property damage/loss or a personal injury
AND you believe that a TSA employee's negligence caused the incident, please fill out this package in it's entirety.
This is a fillable PDF document. Please fill out the form using your computer keyboard or print out the form and
write out the information by hand. Be sure to fill out all the fields completely and accurately.
SIGN the forms and either MAIL them or FAX them to TSA.
INSTRUCTIONS FOR COMPLETING TSA CLAIMS PACKAGE:
CLAIM SUFFICIENCY: In order for a claim to be processed it must have these 5 items (called facial sufficiency)
1. The claim must be SUM CERTAIN -

This means that an exact U.S. Dollar Amount must be entered
in box 12d.
2. The claim must have a SPECIFIC DATE This means there must be a specific date of incidence.
3. The claim must name a SPECIFIC LOCATION - This means that the incident should have a specific place that it happened.
4. It must have a STATEMENT OF FACT In other words, be as detailed as possible. The more accurate and detailed the description, the
faster an investigation and determination will be made. Be sure to remember names, places, and
events. Avoid assumptions, they can actually hinder the investigation and may delay
your claim.
5. A claim must have a SIGNATURE Without a full legal signature (preferably in blue ink), even the most accurate and detailed claim is
not sufficient

NINE USEFUL HINTS:
To speed the process of your claim, the following should be included with your claim:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Purchase receipt of the ORIGINAL item lost or damaged. (If unavailable; credit card statements, bank statements, appraisals, etc.)
Boarding Passes, copies of Baggage Tags, and any other Air Carrier or TSA documents related to this trip
Repair Estimates (if unable to repair, a written statement from the repair shop is required)
Replacement Estimates
Photographs of lost/damaged items (past or present)
Police, Witness, or Incident Reports (if applicable)
Air Carrier/Other company claim reports
Fill out the claim form completely (front and back). Blanks may delay your claim
Submit a claim immediately. Delay in filing a claim can make gathering information difficult or inaccurate

WHERE TO SUBMIT FORMS:
U.S. Mail Address:
TSA Claims Management Branch
601 South 12th Street - TSA 9
Arlington, VA 20598-6009
FAX:
(571) 227-1904
.
Once Submitted, you should receive an acknowledgement letter from TSA within three weeks if you submit the claim by USPS (within 6 days if submitted by
fax). This letter will include a TSA control number and instructions. Use this control number to check the status of your claim, or for any other communications
with the TSA Claims Management Branch.
IMPORTANT:
TSA has seventeen airports that utilize private screening services and does not handle claims for incidents that occur at these airports.
1. San Francisco (SFO), CA
2. Kansas City (MCI), MO
3. Sioux Falls (FSD), SD
4. Rochester (ROC), NY
5. Tupelo (TUP), MS
6. Jackson Hole (JAC), WY

7. Charles Shulz-Sonoma County (STS), CA
8. Key West (EYW), FL
9. Roswell (ROW), NM
10. E. 34th St Heliport (6N5), NY
11. Havre City-County (HVR), MT
12. Lewistown (LWT), MT

13. Glasgow (GGW), MT
14. L.M. Clayton (OLF), MT
15. Sidney-Richland (SDY), MT
16. Dawson Community (GDV), MT
17. Frank Wiley Field (MLS), MT

Claims pertaining to these airports must be filed directly with the company providing screener services at the applicable airport. To find out more about filing a
claim for an incident that occurred at one of these private screening airports, please visit www.TSA.gov.
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CLAIM FOR DAMAGE,
INJURY, OR DEATH
1. Submit To Appropriate Federal Agency:

2. Name, Address of Claimant and claimant's personal representative, if any. (See instructions above.) ( Number, street, city, state, and zip code)

Claims Management Branch
TSA (TSA - 9)
601 South 12th Street
Arlington, Virginia 20598-6009
571.227.1300
[email protected]
3. Type of Employment:
Military

FORM
APPROVED
OMB NO.
11050008

INSTRUCTIONS: Please read the instructions below carefully and supply all the information requested.
You will receive an Acknowledgement Letter and Control Number.

Claimant Information:

Claimant's Representative: (if any)

Full Name:

Full Name:

Address:

Address:

City, State, Zip:

City, State, Zip:

Country:

4. Date of Birth:

Country:

5. Marital Status:
Single

Civilian

6. Day and Date of Incident:
Married

Divorced

7. Time: (A.M. or P.M.)

Widow/Widower

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)

9.

PROPERTY DAMAGE

NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT: (Number, street, city, state, country, and Zip Code)
Full Name:

Address:

City, St. & Zip:

Country:

BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF DAMAGE, AND LOCATION WHERE PROPERTY MAY BE INSPECTED.

10.

PERSONAL INJURY / WRONGFUL DEATH

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..

11.

WITNESSES

1. Name:

Address/Phone:

2. Name:

Address/Phone:

3. Name:

Address/Phone:

12.

AMOUNT OF CLAIM (In U.S. Dollars)

12a. PROPERTY DAMAGE

12b. PERSONAL INJURY

12c. WRONGFUL DEATH

12d. TOTAL Failure to specify maycause
forfeiture of your rights)

I CERTIFY THAT THE AMOUNT OF THE 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 OR CLAIMANT'S REPRESENTATIVE: (See instructions below)

CIVIL PENALTY FOR PRESENTING FRAUDULENT CLAIM
The claimant is liable to the United States Government for the civil
penalty of not less than $5,000 and not more than $10,000, plus three
times the amount of damages sustained by the Government.
(See 31 U.S.C. 3729.)
95-109
Previous editions not usable.

NSN 7540-00-634-4046

13b. PHONE NUMBER OF SIGNATORY:

14. DATE OF CLAIM:

CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
CLAIM OR MAKING FALSE STATEMENTS
Fine of not more than $10,000 or imprisonment for not more than five (5) years
or both. (See 18 U.S.C. 287, 1001.)
Standard Form 95 (Rev. 7-85) (EG)
PRESCRIBED BY DEPT. OF JUSTICE 28 CFR 14.2

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PRIVACY ACT NOTICE
This notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a (e) (3), and concerns the information requested in the letter to which this Notice is attached.
A. Authority: The requested information is solicited pursuant to one or more of the following: 5 U.S.C. 301, 28 U.S.C. 501 et seq., 28 U.S.C. 2671 et seq., 28 C.F.R. Part 14
B. Principal Purpose: The information requested is to be used in evaluating claims.
C. Routine Use: See the Notices of Systems of Records for the agency to whom you are submitting this form for this information.
D. Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the requested information or to execute the form may render your claim “invalid”.

ADDITIONAL INSTRUCTIONS
A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR LEGAL
REPRESENTATIVE AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR MONEY DAMAGES IN A
SUM CERTAIN FOR INJURY TO OR LOSS OF PROPERTY, PERSONAL INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY REASON OF THE INCIDENT. THE CLAIM
MUST BE PRESENTED TO THE APPROPRIATE FEDERAL AGENCY WITHIN TWO YEARS AFTER THE CLAIM ACCRUES

Any instructions or information necessary in the preparation of your claim will be furnished, upon request, by the office indicated in item #1 on the reverse side.
Complete regulations pertaining to claims asserted under the Federal Tort Claims Act can be found in Title 28, Code of Federal Regulations, Part 14. Many
agencies have published supplemental regulations also. If more than one agency is involved, please state each agency.
The claim may be filed by a duly authorized agent or other legal representative, provided evidence satisfactory to the Government is submitted with said claim
establishing express authority to act for the claimant. A claim presented by an agent or legal representative must be presented in the name of the claimant. If the
claim is signed by the agent or legal representative, it must show the title or legal capacity of the person signing and be accompanied by evidence of his/his
authority to present a claim on behalf of the claimant as agent, executor, administrator, parent, guardian or other representative. If claimant intends to file claim for
both personal injury and property damage, claim for both must be shown in item 12 of this form.
The amount claimed should be substantiated by component evidence as follows:
(a)
In support of the claim for personal injury or death, the claimant should submit a written report by the attending physician, showing the nature and
extent of injury, the nature and extent of treatment, the degree of permanent disability, if any, the prognosis, and the period of hospitalization, or incapacitation,
attaching itemized bills for medical, hospital, or burial expenses actually incurred.
(b)
In support of claims for damage to property which has been or can be economically repaired, the claimant should at least two itemized signed
statements or estimates by reliable, disinterested concerns, or, if payment has been made, the itemized signed receipts evidencing payment.
(c)
In support of claims for damage to property which is not economically repairable, or if the property is lost or destroyed, the claimant should submit
statements as to the original cost of the property, the date of purchase, and the value of the property, both before and after the accident. Such statements should
be by disinterested component persons, preferably reputable dealers or officials familiar with the type of property damaged, or by two or more competitive
bidders, and should be certified as being just and correct.
(d)
Failure to completely execute this form or to supply the requested material within two years from the date the allegations accrued may render your claim
“invalid”. A claim is deemed presented when it is received by the appropriate agency, not when it is mailed.
Failure to specify a sum certain will result in an invalid presentation of your claim and may result in forfeiture of your rights.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to:
and to:
Director, Torts Branch Civil Division
Office of Management and Budget
U.S. Department of Justice
Paperwork Reduction Project (1105-0008)
Washington, DC 20530
Washington, DC 20503

INSURANCE COVERAGE
In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance coverage of his vehicle or property.
15. Do you carry accident insurance?

YES, If yes, give name and address of insurance company (number, street, city, state, and zip code) and policy number.

16. Have you filed a claim on your insurance carrier in this instance, and if so, is tfull coverage or deductible?

NO

17. If deductible, state amount

18. If claim has been filed with your carrier, what action has your insurer taken or proposes to take with reference to your claim? (it is necessary that you ascertain these facts)

19. Do you carry Public Liability and property damage insurance?

YES, if yes, give the name and address of the insurance company ( number, street, city, state, and zip code)

NO

SF-95 (Rev.7-85) BACK
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SUPPLEMENTAL INFORMATION - SF-95 CLAIM FOR DAMAGE, INJURY, OR DEATH
20. Claimant Email Address:

21. Did the incident take place at: (please check one)
Passenger Security
Screening Checkpoint?

22. At which Airport did the incident occur?

23. Did you use a Skycap, Porter
service, or other third-party service?
YES

Checked Baggage
Screening Location

OMB number 1652-0039
Expires 11/30/2011

24. Was your checked baggage delayed?

NO

YES, if yes, for how long?
NO

25. If this was a Checked Baggage incident, Why do you believe that TSA was Responsible?

26. Write down your COMPLETE travel itinerary. (include airline names, flight numbers, arrival/departure
times, etc.)

28. At the time of the incident, were you in the Military or a
Federal employee and on official travel?

27. If this is a Checked Baggage incident, please write down your baggage tag numbers.

29. Did you file any type of incident report with the airline, airport, TSA, or any law enforcement agency?

YES, if so, for whom:

YES, if so, please explain and
leave an incident report number:

NO

NO

PLEASE BE SURE TO ATTACH ALL RECEIPTS, ESTIMATES OF REPAIR, APPRAISALS, OR ANY OTHER
DOCUMENTS THAT CAN SUBSTANTIATE THE VALUE OF THE ITEMS THAT WERE LOST OR DAMAGED.
Text
FOR ALL DAMAGED BAGGAGE, YOU MUST GET A REPAIR ESTIMATE
SUBMISSION DIRECTIONS:
1. Use the button on the right to PRINT this form.
2. SAVE this electronic PDF form for your records.

Print Claim

3. SIGN the printed form at the bottom of page 2.

4. INCLUDE all receipts, estimates, proof of flight documents, baggage tags, etc.
5. MAIL or FAX your printed claim and backup documentation.
WHERE TO SUBMIT FORMS:

FAX:
(571) 227-1904

U.S. Mail Address:
TSA Claims Management Branch
601 South 12th Street - TSA 9
Arlington, VA 20598-6009

Once Submitted, you should receive an acknowledgement letter from TSA within three weeks if you submit the claim by USPS (within 6 days if submitted by fax).
This letter will include a TSA control number and instructions. Use this control number to check the status of your claim, or for any other communications with the
TSA Claims Management Branch.
Paperwork Reduction Act Statement of Public Burden: TSA is collecting this information in order to thoroughly investigate and resolve your tort claim against the agency. The public burden for this collection of
information is estimated to be approximately 30 minutes. This is a voluntary collection of information; however, failure to provide this information may delay or hinder the processing of your claim. An agency may not
conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0039,
which expires 11/30/2011.
Privacy Act Statement: AUTHORITY: 28 U.S.C. 1346(b), 1420(b), 2671-2680. PRINCIPAL PURPOSE(S): This information will be used to investigate your claim against the Transportation Security Administration
(TSA). ROUTINE USE(S): This information may be shared with the Department of Justice in review, settlement, defense, and prosecution of claims involving matters over which TSA exercises jurisdiction, or for
routine uses identified in the TSA’s system of records notice, DHS/TSA 009 General Legal Records. DISCLOSURE: Voluntary; failure to furnish the requested information may result in an inability to thoroughly
investigate your claim and may therefore result in an inability to award you payment on your claim.

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