Form SF 95 SF 95 TSA Claims,Outreach, and Debt Branch Tort Claim Package

U.S. Department of Homeland Security
Transportation Security Administration
Claims, Outreach, and Debt Branch
6595 Springfield Center Drive,
TSA-9
Springfield, Virginia 20598-6009

Dear Traveler:

The Transportation Security Administration (TSA) is responsible for the screening of passengers and their baggage at all commercial airports
in the United States and its territories. If you have experienced a loss or damage to your property and you feel that this loss or damage
occurred as a direct result of negligence by a TSA employee, you may file a claim with TSA. If you feel the loss or damage was due to the
negligence of your air carrier, please file a claim directly with the air carrier. If filing with TSA, you must include proof of your loss or
damage as well as evidence of TSA negligence.
In order to protect your rights under Federal law and to file a valid claim, you must send your claim in writing to TSA, stating the
circumstances of your loss and the exact amount you are claiming, within two (2) years of the incident. The claim must be sufficient in order
to be accepted and examined by TSA. Please refer to the instruction sheet accompanying this letter for more information regarding
sufficiency.
This letter is part of the TSA claims package that includes: (1) SF-95 Instructions, (2) SF-95 Claim Form, and (3) SF-95 Supplemental
Information Form. Additional claim packages can be found online at: www.tsa.gov.
Please follow the instructions carefully and fill out the forms completely. While use of these forms is not mandatory, it will help ensure that
you meet the legal requirements for filing a claim. To submit your claim:
Use standard or overnight mail to:
TSA Claims, Outreach, and Debt Branch
6595 Springfield Center Drive, TSA-9
Springfield, VA 20598-6009
OR
Fax your forms and other information to: (571) 227-1904
Once TSA has been presented a sufficient claim, you will be sent a letter of acknowledgment and a control number. Please recognize that
there is often up to a three-week delay for mail sent to Federal facilities due to screening requirements. The Federal Tort Claims Act (FTCA)
governs the way your claim is processed and establishes your rights in regard to your claim. If your claim is denied or has not been resolved
within six months of the date it was properly presented to TSA, you may file suit in an appropriate U.S. District Court. Additional information
about pursuing an FTCA claim may be found in title 28 of the United States Code, sections 1346(b), 1402(b), 2401(b), 2671-2680 and title 28
of the Code of Federal Regulations, sections 14.1-14.11.
We are sorry you experienced difficulties while traveling and hope that this information proves helpful.
Regards,
TSA Claims, Outreach, and Debt Branch

Enclosures: 4

Transportation Security Administration (TSA)
Claims, Outreach, and Debt Branch
Tort Claim Package

OMB number. 1652-0039
Expires 9/30/22

You have downloaded the Tort Claim Package for TSA. If you have suffered property damage/loss or a personal injury
AND you believe that a TSA employee's negligence caused the incident, please fill out this package in its entirety.
This is a fillable PDF document. Please fill out the form using your computer keyboard or print out the form and
write out the information by hand. Be sure to fill out all the fields completely and accurately.
SIGN the forms and VXEPLWWKHPeither E\FAX(0$,/RU0$,/them to TSA.
INSTRUCTIONS FOR COMPLETING TSA CLAIMS PACKAGE:
CLAIM SUFFICIENCY: In order for a claim to be processed it must have these 5 items (called facial sufficiency)
1. The claim must be SUM CERTAIN -

This means that an exact U.S. Dollar Amount must be entered
in box 12d.
2. The claim must have a SPECIFIC DATE This means there must be a specific date of incidence.
3. The claim must name a SPECIFIC LOCATION - This means that the incident should have a specific place that it happened.
In other words, be as detailed as possible. The more accurate and detailed the description, the
4. It must have a STATEMENT OF FACT faster an investigation and determination will be made. Be sure to remember names, places, and
events. Avoid assumptions, they can actually hinder the investigation and may delay
your claim.
Without a full legal signature (preferably in blue ink), even the most accurate and detailed claim
5. A claim must have a SIGNATURE is not sufficient.
NINE USEFUL HINTS:
To speed the process of your claim, the following should be included with your claim:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Purchase receipt of the ORIGINAL item lost or damaged. (If unavailable; credit card statements, bank statements, appraisals, etc.)
Boarding Passes, copies of Baggage Tags, and any other Air Carrier or TSA documents related to this trip
Repair Estimates (if unable to repair, a written statement from the repair shop is required)
Replacement Estimates
Photographs of lost/damaged items (past or present)
Police, Witness, or Incident Reports (if applicable)
Air Carrier/Other company claim reports
Fill out the claim form completely (front and back). Blanks may delay your claim
Submit a claim immediately. Delay in filing a claim can make gathering information difficult or inaccurate

WHERE TO SUBMIT FORMS:
U.S. Mail Address:
TSA Claims, Outreach, and Debt Branch
6595 Springfield Center Drive - TSA 9
Springfield, VA 20598-6009
FAX:
(571) 227-1904
EMAIL:
[email protected]
Once your claim has been received, you will receive an acknowledgment letter from TSA. This letter will include a TSA control number and instructions.
Please use this control number when checking on the status of your claim, or for any other communications with the TSA Claims, Outreach, and Debt
Branch.

IMPORTANT:
TSA has nineteen airports that utilize private screening services and does not handle claims for incidents that occur at these airports.
13. Bozeman, Yellowstone (BZN), MT
14. L.M. Clayton (OLF), MT
15. Sidney-Richland (SDY), MT
20. Portsmouth (PSM), NH
16. Sarasota-Bradenton (SRQ), FL
21. Glasgow (GGW), MT
17. Frank Wiley Field (MLS), MT
22. Yellowstone (WYS), MT
18. Orlando-Sanford (SFD), FL
19. Atlantic City (ACY), NJ
Claims pertaining to these airports must be filed directly with the company providing screener services at the applicable airport. To find out more about filing
a claim for an incident that occurred at one of these private screening airports, please visit www.tsa.gov.
1. San Francisco (SFO), CA
2. Kansas City (MCI), MO
3. Sioux Falls (FSD), SD
4. Rochester (ROC), NY
5. Tupelo (TUP), MS
6. Jackson Hole (JAC), WY

7. Charles Shulz-Sonoma County (STS), CA
8. Key West (EYW), FL
9. Roswell (ROW), NM
10.
Punta Gorda (PGD), FL
11.
Havre City-County (HVR), MT
12. Glacier Park (FCA), MT

Page 1 of 4

INSTRUCTIONS: Please read carefully the instructions on the
reverse side and supply information requested on both sides of this
form. Use additional sheet(s) if necessary. See reverse side for
additional instructions.

CLAIM FOR DAMAGE,
INJURY, OR DEATH
1. Submit to Appropriate Federal Agency:

FORM APPROVED
OMB NO. 1105-0008

2. Name, address of claimant, and claimant's personal representative if any.
(See instructions on reverse). Number, Street, City, State and Zip code.

TSA Claims, Outreach, and Debt
Branch
6595 Springfield Center Drive,
TSA-9
Springfield, VA 20598-6009
3. TYPE OF EMPLOYMENT
MILITARY

4. DATE OF BIRTH

5. MARITAL STATUS

6. DATE AND DAY OF ACCIDENT

7. TIME (A.M. OR P.M.)

CIVILIAN

8. BASIS OF CLAIM (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and property involved, the place of occurrence and
the cause thereof. Use additional pages if necessary).

PROPERTY DAMAGE

9.

NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code).

BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED.
(See instructions on reverse side).

PERSONAL INJURY/WRONGFUL DEATH

10.

STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE THE NAME
OF THE INJURED PERSON OR DECEDENT.

WITNESSES

11.
NAME

ADDRESS (Number, Street, City, State, and Zip Code)

AMOUNT OF CLAIM (in dollars)

12. (See instructions on reverse).
12a. PROPERTY DAMAGE

12b. PERSONAL INJURY

12c. WRONGFUL DEATH

12d. TOTAL (Failure to specify may cause
forfeiture of your rights).

I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN
FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM.
13a. SIGNATURE OF CLAIMANT (See instructions on reverse side).

13b. PHONE NUMBER OF PERSON SIGNING FORM 14. DATE OF SIGNATURE

CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
CLAIM OR MAKING FALSE STATEMENTS

CIVIL PENALTY FOR PRESENTING
FRAUDULENT CLAIM

The claimant is liable to the United States Government for a civil penalty of not less than
$5,000 and not more than $10,000, plus 3 times the amount of damages sustained
by the Government. (See 31 U.S.C. 3729).

Authorized for Local Reproduction
Previous Edition is not Usable
95-109

Fine, imprisonment, or both. (See 18 U.S.C. 287, 1001.)

NSN 7540-00-634-4046

STANDARD FORM 95 (REV. 2/2007)
PRESCRIBED BY DEPT. OF JUSTICE
28 CFR 14.2
Page 2 of 4

INSURANCE COVERAGE
In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance coverage of the vehicle or property.
15. Do you carry accident Insurance?

Yes

If yes, give name and address of insurance company (Number, Street, City, State, and Zip Code) and policy number.

16. Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage or deductible?

Yes

No

No

17. If deductible, state amount.

18. If a claim has been filed with your carrier, what action has your insurer taken or proposed to take with reference to your claim? (It is necessary that you ascertain these facts).

19. Do you carry public liability and property damage insurance?

Yes

If yes, give name and address of insurance carrier (Number, Street, City, State, and Zip Code).

No

INSTRUCTIONS

Claims presented under the Federal Tort Claims Act should be submitted directly to the "appropriate Federal agency" whose
employee(s) was involved in the incident. If the incident involves more than one claimant, each claimant should submit a separate
claim form.
Complete all items - Insert the word NONE where applicable.
A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL
AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR LEGAL
REPRESENTATIVE, AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN
NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR MONEY

Failure to completely execute this form or to supply the requested material within
two years from the date the claim accrued may render your claim invalid. A claim
is deemed presented when it is received by the appropriate agency, not when it is
mailed.
If instruction is needed in completing this form, the agency listed in item #1 on the reverse
side may be contacted. Complete regulations pertaining to claims asserted under the
Federal Tort Claims Act can be found in Title 28, Code of Federal Regulations, Part 14.
Many agencies have published supplementing regulations. If more than one agency is
involved, please state each agency.
The claim may be filled by a duly authorized agent or other legal representative, provided
evidence satisfactory to the Government is submitted with the claim establishing express
authority to act for the claimant. A claim presented by an agent or legal representative
must be presented in the name of the claimant. If the claim is signed by the agent or
legal representative, it must show the title or legal capacity of the person signing and be
accompanied by evidence of his/her authority to present a claim on behalf of the claimant
as agent, executor, administrator, parent, guardian or other representative.
If claimant intends to file for both personal injury and property damage, the amount for
each must be shown in item number 12 of this form.

DAMAGES IN A SUM CERTAIN FOR INJURY TO OR LOSS OF PROPERTY, PERSONAL
INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY REASON OF THE INCIDENT.
THE CLAIM MUST BE PRESENTED TO THE APPROPRIATE FEDERAL AGENCY WITHIN
TWO YEARS AFTER THE CLAIM ACCRUES.

The amount claimed should be substantiated by competent evidence as follows:
(a) In support of the claim for personal injury or death, the claimant should submit a
written report by the attending physician, showing the nature and extent of the injury, the
nature and extent of treatment, the degree of permanent disability, if any, the prognosis,
and the period of hospitalization, or incapacitation, attaching itemized bills for medical,
hospital, or burial expenses actually incurred.
(b) In support of claims for damage to property, which has been or can be economically
repaired, the claimant should submit at least two itemized signed statements or estimates
by reliable, disinterested concerns, or, if payment has been made, the itemized signed
receipts evidencing payment.
(c) In support of claims for damage to property which is not economically repairable, or if
the property is lost or destroyed, the claimant should submit statements as to the original
cost of the property, the date of purchase, and the value of the property, both before and
after the accident. Such statements should be by disinterested competent persons,
preferably reputable dealers or officials familiar with the type of property damaged, or by
two or more competitive bidders, and should be certified as being just and correct.
(d) Failure to specify a sum certain will render your claim invalid and may result in
forfeiture of your rights.

PRIVACY ACT NOTICE
This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and
concerns the information requested in the letter to which this Notice is attached.
A. Authority: The requested information is solicited pursuant to one or more of the
following: 5 U.S.C. 301, 28 U.S.C. 501 et seq., 28 U.S.C. 2671 et seq., 28 C.F.R.
Part 14.

B. Principal Purpose: The information requested is to be used in evaluating claims.
C. Routine Use: See the Notices of Systems of Records for the agency to whom you are
submitting this form for this information.
D. Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the
requested information or to execute the form may render your claim "invalid."

PAPERWORK REDUCTION ACT NOTICE
This notice is solely for the purpose of the Paperwork Reduction Act, 44 U.S.C. 3501. Public reporting burden for this collection of information is estimated to average 6 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Director, Torts
Branch, Attention: Paperwork Reduction Staff, Civil Division, U.S. Department of Justice, Washington, DC 20530 or to the Office of Management and Budget. Do not mail completed
form(s) to these addresses.

STANDARD FORM 95 REV. (2/2007) BACK
Page 3 of 4

SUPPLEMENTAL INFORMATION - SF-95 CLAIM FOR DAMAGE, INJURY, OR DEATH
20. Claimant Email Address:

21. Did the incident take place at: (please check one)
Passenger Security
Screening Checkpoint?

22. At which Airport did the incident occur?

23. Did you use a Skycap, Porter
service, or other third-party service?
YES

Checked Baggage
Screening Location

OMB number 1652-0039
Expires

9/30/2022

24. Was your checked baggage delayed?

NO

YES, if yes, for how long?
NO

25. If this was a Checked Baggage incident, Why do you believe that TSA was Responsible?

26. Write down your COMPLETE travel itinerary. (include airline names, flight numbers, arrival/departure
times, etc.)

28. At the time of the incident, were you in the Military or a
Federal employee and on official travel?

27. If this is a Checked Baggage incident, please write down your baggage tag numbers.

29. Did you file any type of incident report with the airline, airport, TSA, or any law enforcement agency?

YES, if so, for whom:

YES, if so, please explain and
leave an incident report number:

NO

NO

PLEASE BE SURE TO ATTACH ALL RECEIPTS, ESTIMATES OF REPAIR, APPRAISALS, OR ANY OTHER
DOCUMENTS THAT CAN SUBSTANTIATE THE VALUE OF THE ITEMS THAT WERE LOST OR DAMAGED.
FOR ALL DAMAGED BAGGAGE, YOU MUST GET A REPAIR ESTIMATE

SUBMISSION DIRECTIONS:
1. Use the button on the right to PRINT this form.
2. SAVE this electronic PDF form for your records.
3. SIGN the printed form at the bottom of page 2.

Print Claim

4. INCLUDE all receipts, estimates, proof of flight documents, baggage tags, etc.
5. MAIL or FAX your printed claim and backup documentation.
FAX:
(571) 227-1904

U.S. Mail Address:
TSA Claims, Outreach, and Debt
Branch 6595 Springfield Center Drive,
Email: [email protected]
TSA-9
Springfield, VA 20598-6009
Once your claim has been received, you will receive an acknowledgment letter from TSA. This letter will include a TSA control number and instructions.
Please use this control number when checking on the status of your claim, or for any other communications with the TSA Claims, Outreach, and Debt
Branch.
WHERE TO SUBMIT FORMS:

Paperwork Reduction Act Statement of Public Burden: TSA is collecting this information in order to thoroughly investigate and resolve your tort claim against the agency. The public burden for this collection of
information is estimated to be approximately 30 minutes. This is a voluntary collection of information; however, failure to provide this information may delay or hinder the processing of your claim. An agency may not
conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0039,
which expires 9/30/2022. Send comments regarding this burden estimate or collection to: TSA-11, Attention: PRA 1652-0039 TSA Claims, 6595 Springfield Center Drive, Springfield, VA 20598.
Privacy Act Statement: AUTHORITY: 28 U.S.C. 1346(b), 1420(b), 2671-2680. PRINCIPAL PURPOSE(S): This information will be used to investigate your claim against the Transportation Security Administration
(TSA). ROUTINE USE(S): This information may be shared with the Department of Justice in review, settlement, defense, and prosecution of claims involving matters over which TSA exercises jurisdiction, or for
routine uses identified in the TSA’s system of records notices, DHS/ALL-013 DHS Claims Records and DHS/ALL-017 General Legal Records System of Records. DISCLOSURE: Voluntary; failure to furnish the
requested information may result in an inability to thoroughly investigate your claim and may therefore result in an inability to award you payment on your claim.

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