CLAIM FOR DAMAGE, INSTRUCTIONS: Please read DareMIy the on me FORM APPROVED Tevelse we and supply InIorrnation requested on both OMB No Hus--Duns INJURY, OR DEATH Iornt Use additional sneetts) II necessary see reverse sree Tor Instructtens. I strennt ta Applaprla'e TeneIaI Agency 2 None ematmenr and clalmam's personal raptesentauve II any rSee on mum} and code 0.5 Department of the Treasury w. Gary Blackburn I500 Avenue NW 213 5th Ave N.I Ste 300' NasthIle, TN 37219 Washington Dc 20220 Ior Deanna lnntan a TVPE on EMPLOYMENT DATE or DIRTN 5 MARITAL STATUS 5 DATE AND 0F 7 TIME IA OR M) MILIYARV XCIVIUAN Marrted None None None or CLAIM (state In dalall the has and atteneIng the damage, Injury er denlh, paumuand pmpenv Irv/DIde the pIaca atewtnence and me cause Ihereet Us: pages Attaehen Is a Eivens CempIaInt filed In the st Courttor the of TN and the tndtetment of IRS Revenue Agent Samuel Garza In County The facts alleged therein are Incorporated here by reference, Mr Garza's We asked in a recorded telephone conversation in rail why he was permitted to oaIl on Inman without supervistun alter "the last time," The Agency tatlea properly to tratn Gama and to supervIse hIrn PRDPERTV DAMAGE NAME AND OF OWNER IF OTHER THAN CLAIMANT (Numbev. Street CINI State. and ZID cadet None ERIEFLY DESCRIBE THE PROPERTY AND EXYENY OF THE DAMAGE AND THE LOCATION OF THE EE INSPECTED rSee on reverse ma) None In PERSONAL DEATH STATE YHE NATURE AND OF EACH INJURV DR cAusE OF DEATHI WHICH FORMS THE BASIS OF THE CLAIM IF OTHER TNAN STAYE THE NAME OE THE PERSON OR DECEDENT Significant emotional and stress for medlcal treatment has been sought, WITNESSES NAME ADDRESS Number Street on State am he Code} Wltnesses are ltsteo on Not avatlable al Ihts Itrne Mrs. Garza (FNU) 12 (See en levene) AMOUNT OF (In anIIarsI I2: FROPERTV DAMAGE 12b PERSONAI 12c WRONGFUL DEATN 12d TOTAL meyeevse lonettvre or your trams) None INSURANCE COVERAGE In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance coverage of the vehicle or property. 15. Do you carry accident Insurance? ] Yes If yes, give name and address of insurance company (Number, Street, City, State, and Zip Code) and policy number. No None 16. Have you filed a claim with your insurance carrier in this instance, and if so, is'itfull coverage or deductible? Yes No 17. If deductible, state amount. None 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 is necessary that you ascertain these facts). None 19. Do you carry public liability and property damage insurance? Yes If yes, give name and address of insurance carrier (Number, Street, City, State, and Zip Code). No None INSTRUCTIONS Claims presented under the Federal Tort Claims Act should be submitted directly to the "appropriate Federal agency" whose employee(s) was involved in the incident. If the incident involves more than one claimant, each claimant should submit a separate claim form. Complete all items - Insert the word NONE where applicable. A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL AGENCY RECEIVES FROM A CLAIMANT, HIS DULY AUTHORIZED AGENT, OR LEGAL REPRESENTATIVE, AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN NOTIFICATION OF AN INCIDENT, ACCOMPANIED BY A CLAIM FOR MONEY Failure to completely execute this form or to supply the requested material within two years from the date the claim accrued may render your claim invalid. A claim is deemed presented when it is received by the appropriate agency,not when it is mailed. If instruction is needed in completing this form, the agency listed in item #1 on the reverse side may be contacted. 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 published supplementing regulations. If more than one agency is involved, please state each agency. The claim may be filled by a duly authorized agent or other legal representative, provided evidence satisfactory to the Government is submitted with the claim establishing express authority to act for the claimant. A claim presented by an agent or legal representative must be presented in the name of the claimant. If the 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 authority to present a claim on behalf of the claimant as agent, executor, administrator, parent, guardian or other representative. If claimant intends to file for both personal injury and property damage, the amount for each must be shown in item number 12 of this form. DAMAGES IN A SUW1 CERTAIN FOR INJURY TO OR LOSS OF PROPERTY, PERSONAL INJURY, OR DEATH ALLEGED TO HAVE OCCURRED BY REASON OF THE INCIDENT. THE CLAIM MUST BE PRESENTED TO THE APPROPRIATE FEDERAL AGENCY WITHIN TWO YEARS AFTER THE CLAIM ACCRUES. The amount claimed should be substantiated by competent evidence as follows: (a) In support of the claim for personal injury or death, the claimant should submit a written report by the attending physician, showing the nature and extent of the injury, the nature and extent of treatment, the degree of permanent disability, if any, the prognosis, and the period of hospitalization, or incapacitation, attaching itemized bills for medical, hospital, or burial expenses actually incurred. (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 been made, the itemized signed receipts evidencing payment, (c) In support of claims for damage to property which is not economically repalrable, or if the property is lost or destroyed, the claimant should submit statements as to the original cost of the property, the date of purchase, and the value of the property, both before and after the accident. Such statements should be by disinterested competent persons, preferably reputable dealers or officials familiar with the type of property damaged, or by two or more competitive bidders, and should be certified as being just and correct, (d) Failure to specify a sum certain will render your claim invalid and may result in forfeiture of your rights. PRIVACY ACT NOTICE This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and concerns the information requested in the letter to which this Notice is attached. A. Authority: The requested information is solicited pursuant to one or more of the following: 5 U.S.C. 301, 28 U.S.C. 501 etseq., 28 U.S.C. 2671 et seq., 28 C.F.R. Part 14. B. Principal Purpose: The information requested is to be used in evaluating claims. C. Routine Use: See the Notices of Systems of Records for the agency to whom you are submitting this form for this information. D. Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the requested information or to execute the form may render your claim "invalid." PAPERWORK REDUCTION ACT NOTICE This notice is solely for the purpose of the Paperwork Reduction Act, 44 U.S.C. 3501. Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Director, Torts Branch, Attention: Paperwork Reduction Staff, Civil Division, U.S. Department of Justice, Washington, DC 20530 or to the Office of Management and Budget. Do not mail completed form(s) to these addresses. STANDARD FORM 95 REV. (2/2007) BACK