Information Collection

20 CFR 429.102; 429.103 - Filing a Claim (SF-95, OMB No. 1105-0008)

IC 9718 under ICR 202403-0960-011 · OMB 0960-0667.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF-95 20 CFR 429.102; 429.103 - Filing a Claim (SF-95, OMB No. 1105-0008)	Form and Instruction
SF-95 Claim for Damage, Injury, or Death SF-95 (OMB Control No. 1105-0008).pdf www.gsa.gov/reference/forms/claim-for-damage-injury-or-death	Form and Instruction
SF-95 Claim for Damage, Injury, or Death SF-95 (OMB Control No. 1105-0008).pdf www.gsa.gov/reference/forms/claim-for-damage-injury-or-death	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 429.103 20 CFR 429.102

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SF-95	Claim for Damage, Injury, or Death	SF-95 (OMB Control No. 1105-0008).pdf	https://www.gsa.gov/reference/forms/claim-for-damage-injury-or-death	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.