Fillable Printable Employee Claim For Loss Of Or Damage To Personal Property

Employee Claim For Loss Of Or Damage To Personal Property

EMPLOYEE CLAIM FOR LOSS OF OR DAMAGE TO PERSONAL PROPERTY

NOTE: Complete and submit this form, along with supporting documents, to the Regional Counsel's office for claims in excess of $2,500.

PRIVACY ACT INFORMATION: Solicitation of the information is authorized by the Federal Military Personnel and Civilian Claims Act of

1964,31 U.S.C. §3701, et seq, as amended. Disclosure of this information by you is voluntary. The information will be used for filing a claim for

loss of or damage to employee personal property. This information will be transferred to appropriate Federal, State, local, or foreign agencies,

when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in

connection with the hiring or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a

contract, or the issuance of a license, grant, or other benefit. Failure to furnish this information will delay or prevent processing of your claim.

1. NAME OF CLAIMANT 2a. AREA CODE 2b. PHONE NO. 2c. EXT. 3. DATE OF LOSS OR DAMAGE

4a. STREET ADDRESS

4b. CITY 4b. STATE 4c. ZIP CODE

5. SERVICE OR STAFF OFFICE

6. DIVISION OR BRANCH

7. LOCATION OF LOSS OR DAMAGE 8. TOTAL AMOUNT OF CLAIM

9. DESCRIPTION OF PROPERTY (Use additional sheet, if necessary)

ITEMIZED LISTING

(a)

DATE

ACQUIRED

(b)

PURCHASE PRICE

OR VALUE

WHEN ACQUIRED

(c)

VALUE WHEN

LOST OR

DAMAGED

(d)

ESTIMATED REPAIR

OR REPLACEMENT

COST

(e)

10. TYPE OF CLAIM

c. BRIEF STATEMENT OF CIRCUMSTANCES

11. WAS PROPERTY INSURED

a. LOSS

b. DAMAGE

a. YES

b. NO

IF "YES", CHECKED, GIVE THE FOLLOWING INFORMATION:

NAME OF INSURER

CRIMINAL PENALTY FOR PRESENTING A FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS: Fine of not more than $10,000 or

imprisonment for not more than 5 years or both (see 18 U.S.C. §§ 287, 1001)

CIVIL PENALTY FOR PRESENTING A FRAUDULENT CLAIM: The claimant shall forfeit and pay to the United States the sum of not less

than $5,000 and not more than $10,000, plus not less than double the amount of damages which the Government sustained (see 31

U.S.C. § 3729).

CERTIFICATION

I certify that I make this claim with full knowledge of the penalties for wilfully making a false claim and that I am entitled to any payments.

12a. SIGNATURE OF CLAIMANT 12b. DATE

IN WITNESS of the above claim, I on behalf of the claimant, do hereby certify that this claim is being made with full knowledge of the

penalties for wilfully making a false claim.

GSA

FORM 2116 (REV. 7/2002)

Prescribed by ADM 6200.3B

GENERAL SERVICES ADMINISTRATION

ITEMIZE AMOUNT COLLECTED

13a. SIGNATURE OF OTHER CLAIMANT 13b. NAME OF OTHER CLAIMANT

13c. RELATIONSHIP (If any)

13d. DATE