Free Federal Tort Claim - Missouri


File Size: 245.7 kB
Pages: 2
Date: March 13, 2003
File Format: PDF
State: Missouri
Category: Court Forms - Federal
Author: US District Courts
Word Count: 1,602 Words, 8,487 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.moed.uscourts.gov/Forms/Civil/fillFedTortClaimSF95.pdf

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CLAIM FOR DAMAGE, INJURY, OR DEATH
1. Subm it To App ropriate Fede ral Ag ency:

INSTRUCTIONS: Please read carefully the instructions on the reverse side and supply information requested on both sides of this form. Use additional sheet(s) if necessary. See reverse side for additional instructions.

FORM APPROVED OMB NO. 1105-0008 EXPIRES 6-30-01

2. Name, A ddress of claimant an d claimant's p ersonal representative, if any. (See instructions on reverse.) (Number, Street, City, State, and Zip Code)

3. TYPE OF EMPLOYMENT
M I LI TA R Y

4. DATE OF BIRTH

5. MARITAL STATUS

6. DATE AND DAY OF ACCIDENT

7. TIME (A.M. O R P.M .)

CIVILIAN

8. Basis of Claim (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and property involved, the place occurrence and the cause thereof.) (Use additional pages if necessary.)

9.

PROPERTY DAMAGE

NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, City, State, and Zip Code)

BRIEFLY DE SCR IBE TH E PRO PERT Y, NA TUR E AN D EX TENT OF DA MA GE, A ND T HE LOCAT ION W HER E PRO PERT Y M AY B E INSP ECTE D. (See instru ction s on r everse side.)

10.

PERSONAL INJURY/WRONGFUL DEATH

STATE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE NAME OF INJURED PERSON OR DECEDENT.

11. NAME

WITNESSES ADDRESS (Number, Street, City, State, and Zip Code)

12. (See instructions on reverse.) 12a. PROPERTY DAMAGE

AMOUNT OF CLAIM (in dollars) 12b. PERSONAL INJURY 12c. WRONGFUL DEATH

12d. TOTAL (Failure to specify may cause forfeiture of your rights.)

I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE ACCIDENT ABOVE AND AGREE ACCEPT SAID AMOUNT IN FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM. 13 a. SIGNATURE OF CLAIMANT (See instructions on reverse side.) 13b. Phone Number of Signatory 14. DATE OF CLAIM CIVIL PENALTY FOR PRESENTING FRAUDULENT CLAIM The claimant shall forfeit and pay to the United States the sum of not less than and not more than $10,000, plus 3 times the amount of damages sustained by the United States. (See 31 U.S.C. 3729.) 95-108 NSN 7540-00-634-4046 Previous editions not usable CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS Imprisonment for not more than five years and shall be subject to a fine of not than $5,000 and not more than $10,000, plus 3 times the amount of damages sustained by the United States. (See 18 U.S.C.A. 287.) OSTANDARD FORM 95 (Rev. 7-85) PRESCRIBED BY DEPT. OF JUSTICE 28 CFR 14.2

PRIVACY ACT NOTICE
This Notice is provided in ac cordance with the Privacy Act, 5 U.S.C . 552a(e)(3), and concerns the in formation requested in the letter to which this Notice is attached. A. Authority : The requested in formation is solicited pursuan t to one or more of following: 5 U.S.C. 301, 28 U.S.C. 501 et seq., 28 U.S.C. 2671 et seq., 28 C.F.R. Part 14. B. Principal Purpose: The information req uested is to be used in evaluating claims. C. Routine Use: See the Notices of Systems of Record s for the agency to whom you are submitting this form for this information. D. Effect of Failure to Respond: Disclosure is voluntary. Howeve r, failure to the requested information or to execu te the form may rend er your claim

INSTRUCTIONS
Comp lete all items ­ Insert the w ord NON E w here applica ble
A CLAIM SHALL BE DEEM ED TO HAV E BEEN PRESENTED WHEN A F E D E RA L A G E N C Y RECEIVES FROM A CLAIMANT, HIS DU LY A U T H O RI ZE D A G EN T , O R LEGAL REPRESENTATIVE AN EX ECUTED STAN DARD FORM 95 OR OTHER WR ITTEN N O T IF IC A T IO N OF AN I NCI DENT, ACCOM PANI ED BY A C L AI M FO R M O N E Y DA MAG E S IN A SUM CER TAIN F O R IN J U R Y TO O R L O SS O F PRO PERT Y , PERSONAL IN J U RY , O R D E A T H A L L E G E D T O H A V E O C C U R R ED B Y R E A SO N O F T H E IN CI D E N T . T H E CLA I M M U ST BE PRE SE N T E D TO TH E A P PR O P R IA T E F ED E R A L A G E N C Y W IT H IN T W O Y E A R S AFT ER TH E C LAIM ACCRU ES.

Any instructions or information necess ary in the preparation of your claim be furnished, upon request, by the office indicated in Item #1 on the reverse side. Complete regulations pertaining to claims asserted under the Federal Tort Claims Act can be found in Title 28, Code of Federal Regulations, Part 14. Many agencies have pub lished supp lemental regulations also. If more than one a gency is please state each agen cy. The claim may be filed by a duly authorized agent or other legal representative, provided evide nce satisfactory to the Govern ment is su bmitted w ith said claim establishing express authority to act for the claimant. A claim presented by an agen t or legal rep resentat ive m ust be p resented in th e name o f the c laim ant. If claim is signed by the agent or legal representative, it must show the title or legal capacity of the person signing and be accompanied by evidence of his/her to present a claim on behalf of the claimant as agen t, executor, adm inistrator, parent, guardian, or other representative. If claimant intends to file claim for both personal injury and property damage, claim for both must be shown in Item #12 of this form.

(b) In support of claims for damage to property which has been or can be economically repaired, the claimant should submit at least two itemized signed statements or estimates by reliable, disinterested concerns, or if payment has made, the itemized signed receipts evidencing p ayment.

(c) In sup port of claim s for d ama ge to p rope rty wh ich i s not econom ically repairable, or if the property is lost or destroyed, the claimant s hould sub mit ments as to the original cost of the property, the date of purchase, and the value property, both before and after the accident. Such statements should be by disinterested competent persons, preferably reputable dealers or officials familiar the t ype of prop erty d ama ged, or by two o r more comp etitive bidd ers, a nd s hou ld be certified as being ju st and correct.

The amount claimed should be substantiated by competent evidence as (a) In sup port of the claim for person al inj ury or death, the claim ant s hou ld submit a written report by the attending physician, showing the nature and extent injury, the nature an d extent of treatmen t, the degree of perman ent disability, if any, the prognosis, and the period of hospitalization, or incapacitation, attaching Failure to specify a sum certain will result in invalid presentation of your itemized bills for medical, hospital, or burial expenses actually incurred. and may result in forfeiture of your rights. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or other of this collection of information, including suggestions for reducing this burden, to Director, Torts Branch and to the Civil Division Office of Management and Budget U.S. Department of Justice Paperwork Reduction Project (1105-0008) Washington, DC 20530 Washington, DC 20503

(d) Failure to completely execute this form or to supply the requested material within two years from th e date the allegations accrued may render your claim "invalid." A claim is deem ed presented when it is received by the appropriate agency, not when it is mailed.

INSURANCE COVERAGE
In order that subrogation claims be adju dicated, it is essen tial that the claimant p rovide the following information regardin g the insuran ce coverage of his vehicle or 15. Do you carry accid ent insuran ce? Yes If yes, give name and add ress of ins uran ce comp any (Number, Street, City, State, and Zip Code) and policy No

16. Have you filed claim on your insurance carrier in this instance, and if so, is it full coverage or deductible?

17. If deductible, state am ount.

18. If claim has been filed wit h your c arri er, w hat action has your ins ure r taken or proposed to take with referen ce to you r claim? (It is neces sary t hat yo u asc ertain these facts.)

19. Do you carry public liability and property damage insurance?

Yes If yes, give name and a ddress of insuran ce carrier (Number, Street, City, State, and Zip Code). No

O SF 95 (Rev. 7-85) BACK

* U.S. GOVERNMENT PRINTING OFFICE: 1989­241-175