TSA Claims Application

OMB 1652-0039

The TSA Claims, Outreach, and Debt Branch (CODB) requests to continue collection of certain information to investigate tort claims filed against TSA for property damage, property loss, personal injury, or death. TSA needs to collect certain information from claimants, in addition to that collected on the Standard Form 95, to investigate claims properly. TSA is seeking continued approval for two forms associated with this process.

The latest form for TSA Claims Application expires 2022-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SF 95 Filing a Claim Form
DHS_ALL_013 DHS Claims Records_73 FR 63987 (10.28.2008).pdf Supplementary Document
DHS_ALL_017 DHS General Legal Records_76 FR 72428 (11.23.2011).pdf Supplementary Document
privacy_pia_tsa_cms_009.pdf Supplementary Document
28 CFR 14-2.pdf Supplementary Document
1652-0039 TSAClaimsApp 30 DN_87 FR 6889 (2.7.2022).pdf Supplementary Document
1652-0039 TSAClaimsApp 60 DN_86 FR 62563 (11.10.2021).pdf Supplementary Document
1652-0039 TSAClaimsApp SS_2.7.2022.docx Supporting Statement A
Federal Tort Claims Act.pdf Supplementary Document
Filing a Claim Form
Submitting Payment Information Other-Letter

All Historical Document Collections

202202-1652-001 Approved without change	Extension without change of a currently approved collection	2022-02-17
201811-1652-002 Approved without change	Revision of a currently approved collection	2019-01-31
201506-1652-002 Approved with change	Extension without change of a currently approved collection	2015-07-16
201111-1652-006 Approved with change	Extension without change of a currently approved collection	2011-11-29
200904-1652-002 Approved without change	Revision of a currently approved collection	2009-08-31
200606-1652-001 Approved without change	Existing collection in use without an OMB Control Number	2006-06-09

OMB Details

Filing a Claim

Federal Enterprise Architecture: Homeland Security - Border and Transportation Security

Form 95-109

Claim for Damage Injury or Death

www.tsa.gov

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.