OMB control number

Claim for Damage Injury or Death

OMB 1105-0008 · DOJ/LA.

OMB 1105-0008

This form is utilized by those persons making a claim against the United States Government under the Federal Tort Claims Act.

The latest form for Claim for Damage Injury or Death expires 2021-09-30 and is listed under ICR 201807-1105-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form SF 95 Claim for Damage, Injury, or Death	Form and Instruction
28_USC_2672.pdf	Supplementary Document
1105-0008_SF_95_Supporting_Statement A.docx	Supporting Statement A
Claim for Damage Injury or Death	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202601-1105-001	Reinstatement without change of a previously approved collection	2026-01-16
202109-1105-001	Extension without change of a currently approved collection	2021-09-21	Approved without change
201807-1105-001	Extension without change of a currently approved collection	2018-07-17	Approved without change
201505-1105-001	Extension without change of a currently approved collection	2015-05-28	Approved without change
201201-1105-004	Extension without change of a currently approved collection	2012-03-12	Approved without change
200810-1105-001	Extension without change of a currently approved collection	2009-01-26	Approved without change
200801-1105-001	No material or nonsubstantive change to a currently approved collection	2008-01-16	Approved with change
200612-1105-002	No material or nonsubstantive change to a currently approved collection	2006-12-27	Approved with change
200507-1105-002	Extension without change of a currently approved collection	2005-07-21	Approved with change
200203-1105-002	Extension without change of a currently approved collection	2002-03-08	Approved without change
200105-1105-001	Extension without change of a currently approved collection	2001-05-30	Approved without change
199804-1105-001	Revision of a currently approved collection	1998-04-08	Approved without change
199603-1105-002	No material or nonsubstantive change to a currently approved collection	1996-03-29	Approved without change
199408-1105-001	Reinstatement with change of a previously approved collection	1994-08-31	Approved without change
199103-1105-002	Extension without change of a currently approved collection	1991-03-27	Approved without change
198802-1105-002	Extension without change of a currently approved collection	1988-02-23	Approved without change
198503-1105-001	Extension without change of a currently approved collection	1985-03-07	Approved without change
198203-1105-003	Revision of a currently approved collection	1982-03-09	Approved without change
197906-1105-001	Reinstatement with change of a previously approved collection	1979-06-12	Approved without change
197903-1105-001	Extension without change of a currently approved collection	1979-03-16	Withdrawn
197804-1105-001	New collection (Request for a new OMB Control Number)	1978-04-14	Approved without change