Administrative claim; evidence and information to be submitted.

CFR · 2024-01-01 · US · Title 5

(a) (1) An authenticated death certificate or other competent evidence showing cause of death, date of death, and age of the decedent. (2) Decedent's employment or occupation at time of death, including his or her monthly or yearly salary or earnings (if any), and the duration of his or her last employment or occupation. (3) Full names, addresses, birth date, kinship, and marital status of the decedent's survivors, including identification of those survivors who were dependent for support from the decedent at the time of death. (4) Degree of support afforded by the decedent to each survivor dependent on him or her for support at the time of death. (5) Decedent's general physical and mental condition before death. (6) Itemized bills for medical and burial expenses incurred by reason of the incident causing death, or itemized receipts of payment for such expenses. (7) If damages for pain and suffering before death are claimed, a physician's detailed statement specifying the injuries suffered, duration of pain and suffering, any drugs administered for pain, and the decedent's physical condition in the interval between injuries and death. (8) Any other evidence or information which may have a bearing on either the responsibility of the United States for the death or the amount of damages claimed. (b) (1) A written report by the attending physician or dentist setting forth the nature and extent of the injury, nature and extent of treatment, any degree of temporary or permanent dis

official document · source cfr-2024 · id 5:§ 177.105