Information Collection

Claim for Damage Injury or Death

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Damage Injury or Death	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:

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	SF95.pdf	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 %

	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

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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