Form SF 94 SF 94 Statement of Witness

STATEMENT OF WITNESS

(Attach additional sheets if necessary)

D

Please read the Privacy Act
Statement on Page 3

OMB Control Number: 3090-0118
Expiration Date: 8/31/2020

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The
OMB control number for this collection is 3090-0118. We estimate that it will take 20 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of
information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
1. WITNESS INFORMATION
a. NAME OF WITNESS:
b. HOME ADDRESS (Include ZIP Code)

c. E-MAIL ADDRESS
d. WORK TELEPHONE NUMBER

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2. ACCIDENT INFORMATION
a. DID YOU WITNESS THE ACCIDENT?

f. HOME TELEPHONE NUMBER

e. CELLULAR TELEPHONE NUMBER

b. DATE OF ACCIDENT: c. TIME OF ACCIDENT:

a.m. d. TIME YOU ARRIVED AT SCENE?

a.m.

p.m.

p.m.

3. WHERE DID THE ACCIDENT OCCUR? (Give Street Location, City, and State)
4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED.

5. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?

A

6. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY.

7. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY.

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8. DESCRIBE ROAD AND CONDITIONS THAT INFLUENCED THE ACCIDENT (e.g. weather, terrain, debris, road work, time of day).

9. DID YOU NOTICE ANYTHING UNUSUAL PRIOR TO OR DURING THE ACCIDENT?
IF YES, PLEASE DESCRIBE WHAT YOU NOTICED AND WHY YOU THINK IT WAS PERTINENT TO THIS ACCIDENT.

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STANDARD FORM 94 (REV. XX/20XX)
Prescribed by FMR (41 CFR) 102-34

10. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED.

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A

1. Number the vehicles involved as follows:

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Government Vehicle (GOV) #1 - Private Vehicle (POV) #2 - Additional Vehicles GOV or POV as #3, etc. and show direction of
travel by arrow.
(Example: ---->
<----)
1
2
2. Use solid line to show path before accident
Broken line after accident - - - - - - - - 2

2

3. Show pedestrian by ------------------------>
4. Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|
5. Give names or numbers of streets or highways
6. Indicate north by arrow in this compass

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STANDARD FORM 94 (REV. XX/20XX) PAGE 2

NOTES: Include other pertinent information such as: How many drivers/vehicles were involved? Describe the vehicles. How many passengers per vehicle(s)?
Were Police, Fire and/or Rescue on the scene? Was a Police Report completed? Were Police, Fire and/or Rescue present before or after you arrived on the
scene? Describe the accident (provide your detailed account).

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A

PRIVACY ACT STATEMENT
The information on this form is subject to the Privacy Act of 1974 - United States Code set forth at 5 U.S.C. § 552a. Authority
to collect the information is set forth at 40 U.S.C. § 491 and 31 U.S.C. § 7701. The information is required by Federal
Government agencies to administer motor vehicle programs, including maintaining records on accidents involving privately
owned and Federal fleet vehicles, and collecting accident claims resulting from accidents. Federal employees, and employees
under contract, will use the information only in the performance of their official duties. Routine uses of the collected information
may include disclosures to: appropriate Federal, State, or local agencies or contractors when relevant to civil, criminal, or
regulatory investigations or prosecutions; the Office of Personnel Management and the Government Accountability Office for
program evaluation purposes; a Member of Congress or staff in response to a request for assistance by the individual of
record; another Federal agency, including the Department of the Treasury and the Department of Justice, or a court under
judicial proceedings; agency Inspectors General in conducting audits; private insurance and the collection agencies (including
agencies under contract to Treasury to collect debt), and to other agency finance offices for federal management and debt
collection.

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12. WITNESS NAME:
13. WITNESS SIGNATURE:

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DATE:

TIME:

STANDARD FORM 94 (REV. XX/20XX) PAGE 3