Information Collection

Filing a Claim

IC 43964 under ICR 202411-1652-007 · OMB 1652-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF 95 Filing a Claim	Form
Form SF 95 TSA Claims,Outreach, and Debt Branch Tort Claim Package Filing a Claim	Form
SF 95 TSA Claims,Outreach, and Debt Branch Tort Claim Package Revised - sf95cover_packagerevised07-08-15-508.pdf www.tsa.gov	Form
SF 95 TSA Claims,Outreach, and Debt Branch Tort Claim Package Revised - sf95cover_packagerevised07-08-15-508.pdf www.tsa.gov	Form

IC Title:

Filing a Claim

Agency IC Tracking Number:

1652-0039

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 28 CFR 14.2

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	SF 95			www.tsa.gov	Yes	Yes	Fillable Printable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title: DHS Claims Records

FR Citation: 73 FR 63987

Number of Respondents: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,500	-1,500	9,000
Annual IC Time Burden (Hours)	3,750	-750	4,500
Annual IC Cost Burden (Dollars)	2,738	128	2,610

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.

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