§ 25.113 Contents of claim.

(a) A claim under the Federal Tort Claims Act must be presented using Standard Form 95, Claim for Damage, Injury, or Death.

(b) A claim under any other Act may be presented using Standard Form 95. Any claim which is not presented using Standard Form 95 shall include:

(1) The identity of the department, agency, or activity whose act or omission gave rise to the claim;

(2) The full name and mailing address of the claimant. If this mailing address is not claimant's residence, the claimant shall also include residence address;

(3) The date, time, and place of the incident giving rise to the claim;

(4) The amount claimed, supported by independent evidence of property damage or loss, personal injury, or death, as applicable;

(5) A detailed description of the incident giving rise to the claim;

(6) A description of any property damage or loss, including the identity of the owner, if other than the claimant, as applicable;

(7) The nature and extent of the injury, as applicable;

(8) The full name, title, if any, and address of any witness to the incident and a brief statement of the witness' knowledge of the incident;

(9) A description of any insurance carried by the claimant or owner of the property and the status of any insurance claim arising from the incident; and

(10) An agreement by the claimant to accept the total amount claimed in full satisfaction and final settlement of the claim.

(c) A claimant or duly authorized agent or legal representative must sign in ink a claim and any amendment to that claim. If the person's signature does not include the first name, middle initial, if any, and surname, that information must be included in the claim. A married woman must sign her claim in her given name, e.g., “Mary A. Doe,” rather than “Mrs. John Doe.”