Information Collection

TSA Claims Management Branch Program

IC 43964 under ICR 201506-1652-002 · OMB 1652-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1652-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 95-109 Claim for Damage Injury or Death TSA Claims Management Branch Program	Form
Form CMB 6-1-10 Claim Settlement Letter TSA Claims Management Branch Program	Form
95-109 Claim for Damage Injury or Death sf_95_cover_package_revised_07-08-15-508.pdf	Form
CMB 6-1-10 Claim Settlement Letter 0-0-2-Settlement.docx	Form

IC Title:

TSA Claims Management Branch Program

Agency IC Tracking Number:

1652-0039

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 28 CFR 14.2

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	95-109			www.tsa.gov	Yes	Yes	Fillable Printable
Form	CMB 6-1-10				No		Paper Only

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	-2,000	12,000
Annual IC Time Burden (Hours)	5,000	-1,000	6,000
Annual IC Cost Burden (Dollars)	14,800	-2,960	17,760

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.

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