Information Collection

Claim for Damage Injury or Death

IC 11731 under ICR 202601-1105-001 · OMB 1105-0008.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF 95 Claim for Damage, Injury, or Death Claim for Damage Injury or Death	Form and Instruction
SF 95 Claim for Damage, Injury, or Death SF95.pdf www.usdoj.gov/civil/forms/SF95.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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			http://www.usdoj.gov/civil/forms/SF95.pdf	Yes	No	Fillable Printable

Line of Business: Litigation and Judicial Activities

Subfunction: Legal Investigation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	600,000	600,000
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.

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