Filing a Claim

TSA Claims Application

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 95-109 Filing a Claim Form
95-109 Claim for Damage Injury or Death sf_95_cover_package.pdf www.tsa.gov Form

Information Collection (IC) Details

IC Title:	Filing a Claim	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	95-109	Claim for Damage Injury or Death	sf_95_cover_package.pdf	www.tsa.gov	Yes	Yes	Fillable Printable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records
Title: DHS General Legal Records	FR Citation: 76 FR 72428

Number of Respondents: 10,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,200	200	10,000
Annual IC Time Burden (Hours)	5,100	100	5,000
Annual IC Cost Burden (Dollars)	2,550	-12,250	14,800

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.