[Code of Federal Regulations]
[Title 33, Volume 1]
[Revised as of July 1, 2001]
From the U.S. Government Printing Office via GPO Access
[CITE: 33CFR25.113]

[Page 94-95]
 
                TITLE 33--NAVIGATION AND NAVIGABLE WATERS
 
          CHAPTER I--COAST GUARD, DEPARTMENT OF TRANSPORTATION
 
PART 25--CLAIMS--Table of Contents
 
                           Subpart A--General
 
Sec. 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

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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.''