Claim for Damage Injury or Death

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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SF 95 Claim for Damage Injury or Death Form and Instruction
28_USC_2672.pdf Supplementary Document
1105-0008_SF_95_Supporting_Statement_05282015.doc Supporting Statement A
Claim for Damage Injury or Death Form and Instruction

All Historical Document Collections

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197903-1105-001 Withdrawn	Extension without change of a currently approved collection	1979-03-16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