GSA · Official form

SF-95: Claim for Damage, Injury, or Death

Standard Form 95 is the government-wide form for presenting an administrative claim against a federal agency under the Federal Tort Claims Act. You use it when a federal employee's negligence damaged your property or caused injury or death.

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This is the genuine GSA PDF, unmodified. Source: GSA official page.

What is SF-95?

SF-95, Claim for Damage, Injury, or Death, is prescribed under 28 CFR 14.2 and is accepted by federal agencies as the standard way to present a tort claim. The two page form asks for the claimant's information, the date, place, and circumstances of the incident, the nature of the property damage or personal injury, witness information, and the amount claimed for property damage, personal injury, and wrongful death.

The most important entry on the form is the total amount of the claim, stated as a specific dollar figure called a sum certain. A claim without a sum certain is generally not considered validly presented, and the amount you state usually caps what you can later recover in court, so calculate it carefully before signing. The current revision of the form is dated February 2007.

Who files SF-95?

People whose property was damaged by a federal employee acting within the scope of employment, such as in a vehicle accident with a government car
People injured on federal property or by federal activities who want to seek compensation
Survivors or estate representatives presenting a wrongful death claim
Attorneys or agents filing on behalf of a claimant, with evidence of their authority attached

How to fill out SF-95

Identify the federal agency whose employee or activity caused the harm; the claim is presented to that agency, not to GSA or a court.
Fill in your information, the date and place of the incident, and a clear description of what happened and how the government was involved.
State the amount claimed for property damage, personal injury, or death, and enter the total as a specific dollar figure in the sum certain box.
Attach supporting evidence such as repair estimates, medical records and bills, photographs, and witness statements.
Sign the form and send it to the claims office of the responsible agency; in most cases a tort claim must be presented within two years of when it accrued, so check the deadline that applies to your claim.

Worth knowing: SF-95 goes to the agency that caused the harm, not to GSA. Deadlines under the Federal Tort Claims Act are strict; check 28 CFR Part 14 and the agency's claims instructions, and consider legal advice for serious injuries.

Quick fill SF-95 on this page

Prefer to see the form itself while you type? Open SF-95 in the editor to fill it on the actual pages, add a signature, and download.

These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to GSA.

Page 1 25 fields

1. Submit to Appropriate Federal Agency

8. BASIS OF CLAIM (State in detail the known facts and circumstances attending the damage, injury, or death, identifying persons and

2. Name, address of claimant, and claimant's personal representative if any.(See instructions on reverse). Number, Street, City, State and

3. TYPE OF EMPLOYMENT. MILITARY

3. TYPE OF EMPLOYMENT. CIVILIAN

4. Date of Birth. Enter 2 digit month, 2 digit day and 4 digit year.

14. DATE OF SIGNATURE. Enter 2 digit month, 2 digit day and 4 digit year.

5. MARITAL STATUS

11. WITNESSES. NAME. Line 1 of 3.

11. WITNESSES. ADDRESS (Number, Street, City, State, and Zip Code). Line 1 of 3.

11. WITNESSES. ADDRESS (Number, Street, City, State, and Zip Code). Line 2 of 3.

11. WITNESSES. ADDRESS (Number, Street, City, State, and Zip Code). Line 3 of 3.

11. WITNESSES. NAME. Line 2 of 3.

11. WITNESSES. NAME. Line 3 of 3.

13b. PHONE NUMBER OF PERSON SIGNING FORM

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

BRIEFLY DESCRIBE THE PROPERTY, NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED. (See instructions

10. PERSONAL INJURY/WRONGFUL DEATH. STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH, WHICH FORMS THE BASIS OF THE CLAIM. IF

7. TIME (A.M. OR P.M.)

6. DAY OF ACCIDENT

6. DATE OF ACCIDENT. Enter 2 digit month, 2 digit day and 4 digit year.

12a. PROPERTY DAMAGE

12b. PERSONAL INJURY

12c. WRONGFUL DEATH

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

Page 2 11 fields

15. Do you carry accident Insurance? Yes. If yes, give name and address of insurance company (Number, Street, City, State, and Zip Code)

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

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

19. Do you carry public liability and property damage insurance? No

16. Have you filed a claim with your insurance carrier in this instance, and if so, is it full coverage or deductible? No

15. Do you carry accident Insurance? No

15. Do you carry accident Insurance? If yes, give name and address of insurance company (Number, Street, City, State, and Zip Code) and

19. Do you carry public liability and property damage insurance? If yes, give name and address of insurance carrier (Number, Street, City,

18. If a claim has been filed with your carrier, what action has your insurer taken or proposed to take with reference to your claim? (It

16. Specify if vehicle is full coverage or deductible

17. If deductible, state amount.

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Frequently asked questions

Where do I send SF-95?

To the federal agency responsible for the harm, for example the VA for a VA hospital incident or USPS for a postal vehicle accident. Most agencies list a tort claims mailing address on their website. GSA publishes the form but does not receive claims against other agencies.

What happens after I file?

The agency investigates and can pay the claim, negotiate, or deny it. If the agency denies the claim in writing, or six months pass without a final decision, you generally then have the option of filing suit in federal court. Many claimants consult an attorney at that stage.

What if I leave the total amount blank?

Do not. A claim without a stated sum certain is generally treated as not properly presented, which can cost you the claim entirely if the filing deadline passes. State a specific total dollar amount in box 12d.

SF-95: Claim for Damage, Injury, or Death

What is SF-95?

Who files SF-95?

How to fill out SF-95

Quick fill SF-95 on this page

Frequently asked questions

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