1105-0008_SF_95_Supporting_Statement_05282015

_{SUPPORTING STATEMENT}

Part A. Justification:

_{1. Necessity of Information Collection:}

A lawsuit against the United States Government may be brought under the Federal Tort Claims Act only if the plaintiff has first sought administrative claim relief from the appropriate Federal agency involved. The claim must be presented in writing, and this requirement can be satisfied by utilizing the Claim for Damage, Injury, or Death Form (Standard Form 95 or SF 95). 28

U.S.C. § 2672, et seq. and 28 C.F.R. Part 14 authorize the use of the Claim for Damage, Injury, or Death Form (SF 95) to carry out the provisions of 28 U.S.C. § 2675.

The identifiable information included on this form is the name, address, date of birth, telephone number, marital status, and type of employment of the claimant.

The Claim for Damage, Injury, or Death Form (SF 95) has not undergone any significant changes since the last OMB approval. The annual burden estimate has remained the same.

2. Needs and Uses:

The Claim for Damage, Injury, or Death Form (SF 95) is used by persons, businesses, or State, Local or Tribal Governments presenting administrative tort claims under the Federal Tort Claims Act, 28 U.S.C. § 2671, et seq. on a case-by-case basis. The information provided on the Claim for Damage, Injury, or Death Form (SF 95), including the identifiable information, is necessary for the Federal agency to investigate and evaluate the claim. The information is shared only with the appropriate personnel within the Federal agency. Agencies are tasked with investigating

these claims to ensure that justified claims are resolved.

3. Information Technology

The Claim for Damage, Injury, or Death Form (SF 95) is available electronically. It can be obtained through the Civil Division’s web site (http://www.usdoj.gov/civil/home.html) or through the U.S. Government’s forms web site (http://www.forms.gov). However, it was decided not to automate this form. Submitted claims can require extensive supporting documentation that generally cannot be supplied electronically (for example, estimates for property damage, medical records/bills, employment/wage certification, death certificates and tax returns). Allowing part of the submission to take place electronically, with hard copy, supporting documentation to follow, would result in a fragmented process. In addition, some individuals may never send the follow-up information which would leave Federal agencies with open claims that could not be reconciled.

4. Efforts to Identify Duplication:

The Claim for Damage, Injury, or Death Form (SF 95) is unique in that it is the only form that captures the information required to process a claim under the Federal Tort Claims Act.

5. Methods to Minimize Burden on Small Entities:

The Claim for Damage, Injury, or Death Form (SF 95) does not impact small businesses or other small entities. Its impact is primarily on the individual. The Civil Division has minimized the information required to complete the form so as to minimize the burden placed on the public. Only essential data is required to process a claim. Additionally, individuals need only make one written submission to file a claim under the Federal Tort Claims Act.

_{6. Consequences of Less Frequent Collection:}

The program could not be effectively implemented without the Claim for Damage, Injury, or Death Form (SF 95). Without standardization of key information to process the claim, resources would be expended on non-productive data collection.

7. Special Circumstances Influencing Collection:

There are no special circumstances that would cause an information collection to be conducted in any unusual manner.

8. Federal Register/Consultations:

A 60 day notice has been published in the Federal Register (80 FR 8900). A 30 day notice has been published in the Federal Register (80 FR 23288).

_{9. Payment/Gift to Claimant:}

The Civil Division does not provide payments or gifts to respondents.

10. Assurance of Confidentiality:

Information collected is in accordance with the Privacy Act, 5 U.S.C. § 552a(e)(3). The reverse side of the Claim for Damage, Injury, or Death Form (SF 95), under the Privacy Act Notice, Item D, states that disclosure of the information collected through the SF 95 is voluntary. The authority to request the information is solicited pursuant to one or more of the following:

5 U.S.C. § 301 (General statutory authority for development and review of regulations relating to

Department of Justice matters), 28 U.S.C. § 501 et seq. (Legal authority to collect information),

28 U.S.C. § 2671 (Tort Claims Procedures), and 28 C.F.R. Part 14 (Department of Justice regulations governing claims asserted under the Federal Tort Claims Act).

11. Justification for Sensitive Questions:

The Claim for Damage, Injury, or Death Form (SF 95) does not ask any questions of a sensitive nature.

12. Estimate of Hour Burden:

This collection totals 600,000 burden hours annually. Each respondent will take six hours to complete and present the Claim for Damage, Injury, or Death Form (SF 95). Since there are approximately 100,000 annual respondents, there will be a total of 600,000 burden hours annually.

The estimated total annual cost burden to respondents resulting from the collection of information is $6,000,000. This was obtained by multiplying the 600,000 burden hours by $10 per hour. (600,000 hours x $10/hour = $6,000,000).

13. Estimate of Cost Burden:

The Civil Division of the United States Department of Justice cannot estimate the annual cost burden to collect the information. The Department of Justice has no way of estimating the annual record keeping hours burden because of the multitude of variables within the control of those that file claims.

_{14. Estimated Annualized Cost to Federal Government:}

_{Annualized costs to the Federal Government:}

Salary:	$521,845
Printing:	$22,329
Postage:	$5,582
Other Overhead:	$111,645
Total Costs:	$603,750

15. Program Changes:

The estimate of the cost burden in question 12 remains the same. The estimated annualized cost to the Federal government in question 14 remains the same.

_{16. Publication:}

This information collection will not result in the publication of any document.

17. Expiration Date Approval:

The Civil Division is seeking approval to not display the expiration date on the Claim for Damage, Injury, or Death Form (SF 95). An expiration date on the form will result in unnecessary confusion for the respondent.

18. Exceptions to Certification Statement:

There are no exceptions to the certification statement. Part B. Statistical Methods.

This information collection does not require the employment of statistical methods.