SF 95 is Standard Form 95, the Claim for Damage, Injury, or Death that a person presents to a federal agency under the Federal Tort Claims Act. The form is prescribed by the Department of Justice (28 CFR 14.2) and published on the GSA forms site. You use it to describe an incident, the property damage, injury or death it caused, and the sum you claim. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the claim itself goes to the federal agency involved, as described below.
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What is SF 95?
Standard Form 95 (SF 95), Claim for Damage, Injury, or Death, is the form on which a claimant presents a claim under the Federal Tort Claims Act to the federal agency whose employee or employees were involved in an incident, stating the facts and a sum certain in dollars.
The form is prescribed by the Department of Justice under 28 CFR 14.2, carries OMB No. 1105-0008, and the revision printed on it is STANDARD FORM 95 (REV. 2/2007). The General Services Administration (GSA) lists it as form number SF95 on its forms page. The printed notes say the previous edition is not usable.
The form covers three kinds of loss, each with its own item: property damage (item 9), personal injury or wrongful death (item 10) and the amount claimed for each (item 12). It also asks for witnesses (item 11) and insurance coverage (items 15 to 19), which the form says is needed so that subrogation claims may be adjudicated.
Complete regulations for these claims are in Title 28, Code of Federal Regulations, Part 14, and the form notes that many agencies have published supplementing regulations. The form is not sent to the Department of Justice: it is submitted to the appropriate federal agency.
Who needs to file SF 95?
Anyone presenting a claim under the Federal Tort Claims Act for injury to or loss of property, personal injury or death allegedly caused by an incident involving a federal employee uses SF 95, or may use other written notification of the incident accompanied by a claim for money in a sum certain.
- Each claimant. If the incident involves more than one claimant, each claimant should submit a separate claim form.
- Agents and legal representatives. A duly authorized agent or other legal representative may file the claim, but must submit evidence satisfactory to the Government of express authority to act for the claimant. The claim must be presented in the claimant's name. A representative who signs must show a title or legal capacity (for example agent, executor, administrator, parent or guardian) and attach evidence of authority.
- Claims involving more than one agency. If more than one agency is involved, state each agency on the form.
The form itself sets no other eligibility test, so questions about whether your situation fits should go to the agency listed in item 1.
When to file SF 95
The claim must be presented to the appropriate federal agency within two years after the claim accrues. The form warns that failing to completely execute it or to supply the requested material within two years from the date the claim accrued may render the claim invalid.
A claim is deemed presented when the agency receives it, not when it is mailed. Allow for delivery time, because a mailing date does not count. A claim is deemed presented when the agency receives an executed SF 95 or other written notification of an incident, accompanied by a claim for money in a sum certain, from the claimant, an authorized agent or a legal representative. The form sets no other deadline and gives no processing time.
Documents you need
- Personal injury or death: a written report by the attending physician showing the nature and extent of the injury and treatment, any permanent disability, the prognosis, and the period of hospitalization or incapacitation.
- Personal injury or death: itemized bills for medical, hospital or burial expenses actually incurred.
- Property damage that can be economically repaired: at least two itemized signed statements or estimates by reliable, disinterested concerns, or itemized signed receipts if payment has been made.
- Property not economically repairable, lost or destroyed: statements of the original cost, the date of purchase, and the value before and after the accident, from disinterested competent persons, certified as just and correct.
- Claim filed by an agent or legal representative: evidence of express authority to act for the claimant, plus the signer's title or legal capacity on the form.
- Additional sheets, if needed, when the space on the form is not enough for the basis of claim or other items.
How to fill out SF 95
Name the federal agency
In item 1, enter the appropriate federal agency whose employee or employees were involved in the incident. If more than one agency is involved, state each one.
Enter claimant and representative details
Item 2: name and address (number, street, city, state, ZIP code) of the claimant and of the personal representative, if any.
Complete the personal details
Item 3: check MILITARY or CIVILIAN for type of employment. Then enter date of birth (item 4) and marital status (item 5).
Give the date and time
Item 6: date and day of the accident. Item 7: the time, marking A.M. or P.M.
State the basis of claim
Item 8: state in detail the known facts and circumstances, identifying the persons and property involved, the place of occurrence and the cause. Use additional pages if necessary.
Describe the property damage
Item 9: give the owner's name and address if other than the claimant, and describe the property, the nature and extent of the damage and where it may be inspected. Enter NONE if it does not apply.
Describe injury or wrongful death
Item 10: state the nature and extent of each injury or the cause of death. If the injured person or decedent is not the claimant, give that person's name.
List witnesses
Item 11: enter each witness's name and address (number, street, city, state, ZIP code), or NONE.
Enter the amount of claim
Item 12: enter dollar amounts in 12a (property damage), 12b (personal injury) and 12c (wrongful death), then the total in 12d. Failure to specify may cause forfeiture of your rights.
Sign and date the claim
Item 13a: signature of the claimant, or of an authorized agent showing title or legal capacity. Enter the phone number of the person signing (13b) and the date (item 14).
Answer the insurance questions
Items 15 to 19 ask about accident insurance, any claim filed with your carrier and whether it is full coverage or deductible, the deductible amount, the insurer's action, and public liability and property damage insurance. Give insurer names, addresses and policy numbers where asked.
Review and download the completed PDF
Check that no item is blank and that the sum certain and signature are present. Download or print the completed PDF from FillingPDF, add the supporting evidence and send it as described under How to submit.
How to submit SF 95
Submit SF 95 directly to the federal agency whose employee or employees were involved in the incident; the form names no other channel.
- Where it goes. Enter that agency's name and address in item 1, Submit to Appropriate Federal Agency. If more than one agency is involved, state each one.
- Questions. If you need help completing the form, the agency listed in item 1 may be contacted.
- Delivery. The claim counts only when the agency receives it, so use a delivery method that lets you confirm receipt.
- Where not to send it. The Paperwork Reduction Act notice gives a Department of Justice address for comments on the reporting burden; it says not to mail completed forms to those addresses.
- Agents. A representative who files for you must attach evidence of authority to act.
The form gives no mailing address, portal or fee, because each agency has its own. FillingPDF lets you fill out and download the PDF; submission follows the agency's channels above.
Common mistakes to avoid
- Leaving items blank. The instructions say to complete all items and to insert the word NONE where applicable.
- Not stating a sum certain in item 12. The form says failure to specify a sum certain renders the claim invalid and may result in forfeiture of rights.
- Counting the mailing date as the filing date. A claim is deemed presented only when the appropriate agency receives it.
- Waiting past two years after the claim accrues, which may render the claim invalid.
- Mailing the completed form to the Department of Justice address in the Paperwork Reduction Act notice, which says not to mail completed forms there.
- Putting several claimants on one form when each claimant should submit a separate claim form.
- Signing as an agent or representative without showing title or legal capacity and without evidence of authority.
- Claiming both property damage and personal injury without showing the amount for each in item 12.
- Submitting a property damage claim without the required estimates, receipts or value statements.
Frequently asked questions
What is SF 95 used for?
SF 95 is the Standard Form 95 claim for damage, injury, or death under the Federal Tort Claims Act. You present it to the federal agency whose employee was involved in the incident, stating the facts and a sum certain for property damage, personal injury or wrongful death.
Where do I send SF 95?
Send it directly to the appropriate federal agency whose employee or employees were involved, and enter that agency in item 1. The form gives no address of its own, so contact the agency listed in item 1 for instructions. Do not mail it to the Department of Justice address in the burden notice.
How long do I have to file an SF 95 claim?
The claim must be presented to the agency within two years after it accrues. It counts as presented only when the agency receives it, not when you mail it. Missing the two-year window may render the claim invalid.
What does "sum certain" mean on SF 95?
It means a specific dollar amount that you state in item 12 for property damage, personal injury or wrongful death, with a total in 12d. The form says that failing to specify a sum certain renders the claim invalid and may result in forfeiture of your rights.
Do I need to attach documents to SF 95?
The amount claimed should be supported by competent evidence. For injury or death, that means a physician's report and itemized bills; for property damage, estimates, receipts or value statements, depending on whether it can be repaired. An agent must also attach proof of authority.
Can someone else file SF 95 for me?
Yes. A duly authorized agent or legal representative may file, if evidence of express authority accompanies the claim. It must be presented in your name, and the signer must show a title or legal capacity, such as agent, executor, administrator, parent or guardian.
Do I file one SF 95 for several claimants?
No. If the incident involves more than one claimant, each claimant should submit a separate claim form. Where a claimant has both property damage and personal injury, one form is used and each amount is shown in item 12.
Can I fill out the SF 95 form online?
You can fill out the SF 95 PDF online on FillingPDF and download or print it. FillingPDF is independent of GSA, the Department of Justice and the agencies, and does not file claims; you deliver the claim to the federal agency yourself.
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