Claim for Damage Injury or Death

ICR 201807-1105-001

OMB: 1105-0008

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Unchanged
Supplementary Document
2012-03-12
Supporting Statement A
2015-05-28
IC Document Collections
IC ID
Document
Title
Status
11731 Unchanged
ICR Details
1105-0008 201807-1105-001
Active 201505-1105-001
DOJ/LA CIV-2008-1
Claim for Damage Injury or Death
Extension without change of a currently approved collection   No
Regular
Approved without change 09/17/2018
Retrieve Notice of Action (NOA) 07/17/2018
  Inventory as of this Action Requested Previously Approved
09/30/2021 36 Months From Approved 09/30/2018
100,000 0 100,000
600,000 0 600,000
0 0 0

This form is utilized by those persons making a claim against the United States Government under the Federal Tort Claims Act.

US Code: 28 USC 2672 Name of Law: Federal Tort Claims Act
  
None

Not associated with rulemaking

  83 FR 22992 05/17/2018
83 FR 32688 07/13/2018
No

1
IC Title Form No. Form Name
Claim for Damage Injury or Death SF 95 Claim for Damage, Injury, or Death

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 100,000 100,000 0 0 0 0
Annual Time Burden (Hours) 600,000 600,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$603,750
No
    No
    No
No
No
No
Uncollected
James Touhey 202 616-4292

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/17/2018


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