Information Collection

Claim for Damage Injury or Death

IC 11731 under ICR 201505-1105-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SF 95 Claim for Damage Injury or Death Form and Instruction
SF 95 Claim for Damage, Injury, or Death SF95.pdf www.usdoj.gov/civil/forms/SF95.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Damage Injury or Death	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SF 95	Claim for Damage, Injury, or Death	SF95.pdf	http://www.usdoj.gov/civil/forms/SF95.pdf	Yes	No	Fillable Printable

Line of Business: Litigation and Judicial Activities

Subfunction: Legal Investigation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	600,000	600,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.