SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL PROPERTY

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP90-00530R000701780020-2
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 15
• Document Creation Date: December 23, 2016
• Document Release Date: March 13, 2013
• Sequence Number: 20
• Publication Date: October 30, 1984
• Content Type: REGULATION

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PART I
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
The Military Personnel and Civilian Employees' Claims Act of 1964
provides for the settlement of claims against the United States by civilian
officers and employees of the Department of Justice For damage to or loss of
personal property incident to their service with the Department. Authority
for handling such claims was vested in the Attorney General for employees of
the Department of Justice, and authority to settle all claims of Bureau
employees has been delegated to the Director by Department of Justice Order
[[2110.238 effective 6/21/84.]
19-1 SETTLEMENT OF CLAIMS
(1) "Settle" means consider, ascertain, adjust, determine, and
dispose of any claim, whether by full or partial allowance or disallowance.
All claims filed under the Act are subject to the approval of the Director.
(2) The acceptance of an award by the claimant constitutes a
release for the United States of all liability to the employee based on the
occurrence giving rise to the claim for which the award is made. The claimant
accepts an award upon negotiation of the settlement check. Prior to
negotiating the settlement check, a claimant may discuss the amount of the
award with the approving official.
19-2 ALLOWABLE DAMAGES AND/OR LOSSES
Claims are allowable under the Act for damage to or loss of
personal property if:
(1) Such damage or loss was incident to the employee's service
with the Department and the possession of that property is determined to be
reasonable, useful, or proper under the particular circumstances involved.
(2) Such damage or loss was not caused either wholly or partially
by the negligent or wrongful act of the claimant, his/her agent, dependent, or
co?worker. Negligence is defined as the failure to exercise the care which a
reasonable and prudent person would have exercised under the same or similar
circumstances.
(3) Such damage or loss involved:
(a) Personal property located in quarters when such quarters
were assigned or provided in kind by the Federal Government, or when such
quarters are located outside the United States and the employee involved is
not a local or native resident of the area.
(b) Personal property located in a storage place designated
or authorized by the employee's supervisor or an official who has been
delegated the authority to approve such authorization for storage of the
property.
?
(c) Personal property, including personal clothing,
subjected to extraordinary risks in the performance of duty, or hazardous
circumstances beyond the control of the employee while at the place of
employment. (Ordinarily, a sudden, unexpected act of God does not constitute
an extraordinary risk.)
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SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
(d) Personal property transferred under a Government Bill of
Lading, or by a commercial carrier which operates in intrastate or interstate
commerce under an authorized certificate or permit relative to a change of
duty station or other authorized transfer or travel.
(e) Property owned by the United States when the employee is
financially responsible for it.
(f) Personal property used for the benefit of the Government
at the direction of a superior authority.
19-3 DAMAGES AND/OR LOSSES NOT ALLOWABLE
Claims are not allowable under the Act for damage to or loss of
personal property if:
(1) The loss or damage occurred at quarters occupied by the
claimant within one of the fifty states or the District of Columbia, unless
the quarters were assigned to him/her or otherwise provided in kind by the .
Government.
(2) Such damage or loss involved:
[(a) Property used primarily in Government offices for the
[ personal convenience, gratification, comfort, diversion, or entertainment of
[ the employee.]
[(11)]
business or profit.
Property acquired for sale, or being used for personal
[(c)1 Property acquired, possessed or transported in violation
of law or regulations.
[(d)] Amounts recoverable from insurers or carriers, or
pursuant to the performance of a contract.
[(e)] Transportation losses involving baggage, household
goods, or other shipments if the claimant chose an unlicensed carrier without
obtaining prior approval from the Director or the official who authorized the
employee's change of station.
[(f)] Contractors or other persons who, while under contract
to the Government, caused an incident which resulted in the loss or damage to
an employee's personal property. Though the Government is secondarily
responsible primary liability rests with the contractor. (The term
contractor" excludes those carriers referred to in 19-2 (3)(d).)
[(g)] Motor vehicles or trailers when mileage payment is
authorized, unless extraordinary risks are involved that would permit the
employee to be covered by 19-2 (3)(c). (Generally, uninsured collisions
resulting from wanton negligence when mileage is authorized are not
compensable under the Act.)
[(h)] Loss or damage of articles sent through United States or
international mail systems, or loss or damage of articles of extraordinary
value. Such articles should be insured by owners. (See 19-12.)
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SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
[(i) Money and currency, unless it can be shown that the
employee is required by the nature of his/her assignment to carry money or
currency. Reimbursement for loss of money or currency shall be limited to an
amount determined to have been reasonable for the claimant to have had in
his/her possession at the time of the incident. It must be conclusively shown
that the money or currency was in a locked container and that the quarters
themselves were locked, or that the loss was the direct result of an incident
occurring because the employee was known to be on official business.]
19-4 INFORMATION TO EMPLOYEES ? INSURANCE
Most claims for damages to or loss of personal property arise
during shipment and storage of household goods incident to permanent changes
of station. Employees should be informed of household goods incident to
permanent changes of station. Employees should be informed prior to such
moves of the contents and applicability of this Order. They should also be
informed of the advisability of obtaining commercial insurance to cover such
shipments since damages or losses that can be paid are limited by the Act and
repayment for damages or losses incurred may not be as rapid as the payment of
insurance claims. Such insurance is desirable to cover claims specifically
excluded or limited by this Order. Employees should be advised of the
difference between losses covered by carriers based on released weight of
shipments and losses covered by commercial insurance.
19-5 CLAIMS INVOLVING PARTIES OTHER THAN THE GOVERNMENT
In cases where loss or -damage of personal property has occurred,
employees are cautioned not to sign a release, or a statement containing a
release, if there is a'possibility of recovery against a carrier;
Hwarehouseriinsurer or other contractor. Employees must file and diligently
pursue any claim they may have against parties other than the Government prior
to submission of a claim under the Act. Employees are further cautioned not
to sign any release or statement that property was received in good condition
unless and until they have performed a reasonable inspection and are satisfied
that no loss or damage occurred. Failure to file and pursue such a claim, or
the signing of a release or statement of arrival in good condition will
prejudice the handling of the claim under the Act.
19-6 ASSIGNMENTS
A claimant shall subrogate, i.e., assign, to the United States
Government his/her right, title and interest in any claim he/she may have
against a carrier, insurer or other party for damage to or loss of personal
property for which a settlement was received under the Act. The assignment
shall extend to the amount of the settlement payment accepted by the claimant.
In addition, the claimant shall furnish the Department such evidence as may be
necessary to enforce the claim against the carrier, insurer, or other party.
After payment of his/her claim by the United States, the claimant will, upon
receipt of any payment from a carrier or insurer, pay the proceeds to the
United States to the extent of the payment received by him/her from the United
States. Such amount should be forwarded by the claimant to the Voucher and
Payroll Section, Administrative Services Division.
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SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
19-7 LIMITATION OF ATTORNEY FEES
No more than 10 percent of the amount paid in settlement of each
individual claim shall be paid, delivered to, or received by any agent or
attorney on account of services rendered in connection with that claim (Title
31, USC, ? 243).
19-8 FILING OF CLAIMS -
? All claims allowable under the Act shall be filed with the
Director, FBI, in accordance with the procedures set forth herein.
(1) Who May File a Claim
(a) A claim may be filed by any civilian officer or employee
of the Department for damages to or loss of personal property incident to
his-flier service in the Department.
(b) If a person is deceased, an allowable claim may be filed
by the personal representative of the decedent's estate, or the decedent's
surviving spouse, children, father or mother or both, or brother(s) or
sister(s) or both, provided such claim arose before, concurrently with, or
after the decedent's death. Claims of survivors shall be settled and paid in
the order listed.
(c) .Claims filed by an agent or legal representative of a
claimant must be supported by a power of attorney or other satisfactory
evidence of authority to file on behalf of the claimant.
(2) Time Limitation on Filing Claims
A claim should be presented as soon as possible after
discovery of the damage or loss. Immediate action by a claimant will
facilitate the processing of his/her claim. Delays cause difficulty in
securing statements of essential witnesses and necessary documents. In order
for any claim to be considered for any form of settlement, it must be
presented in writing within a two?year period after the occurrence of the
loss, except that if the loss occurred in time of war or in time of armed
conflict in which the claimant is a Government participant, or if such a war
or armed conflict intervenes within two years after the occurrence of the loss
and good cause is shown, the claim may be presented not later than two years
after that cause ceases to exist, or two years after the war or conflict is
terminated, whichever is earlier. For purposes of the Act, the beginning and
ending of an armed conflict are the dates established by concurrent resolution
of Congress or by a proclamation of the President.
(3) Maximum Amounts Allowable Under the Act
(a) The maximum amount which may be paid for a single claim
is $25,000. The submission of two or more claims arising from the same
incident in order to circumvent the statutory ceiling is prohibited. However,
if upon submission of a claim additional losses or damage are discovered,
supplemental claims may be filed but all the claims shall be processed and
considered as one claim under the Act.
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PART I
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
(b) [Claims for Damage in Foreign Countries. Employees with
claims arising from incidents occurring in foreign countries on or after
December 30, 1978, may be paid an amount not to exceed $40,000 provided the
employee was evacuated from that country on or after December 31, 1978, in
accordance with a recommendation or order of the Secretary of State or other
competent authority which was made in response to incidents of political
unrest or hostile acts by people in that country, and that damage or loss
resulted from that evacuation or from any such incident or hostile act; or
that damage or loss resulted from acts of mob violence, terrorist attacks, or
other hostile acts, directed against the United States Government or its
officers or employees. Any claim which falls in this category which has been
settled prior to December 12, 1980, may be resubmitted for settlement for any
amount not paid initially by reasons of the previous $15,000 limitation.]
[(c)] Employees with claims in excess of the statutory ceiling
are not prohibited from recovering the full amount since they may request the
Congress to enact private relief legislation on their behalf in lieu of
settlement under the Act. Within 15 days from the date the claim is settled,
the claimant may submit a written request to suspend payment of the settlement
amount and to request the Congress to enact private relief legislation. Each
organization head is responsible for insuring that the Congress is furnished
adequate information to consider the claim. All such requests must be
submitted through the Assistant Attorney General for Administration,
Department of Justice, to the Comptroller General of the United States.
[(d) _Minimum Claims. Claims are not payable for damage to or
loss of property in an amount less than $25.00.]
(4) Submission of Claim
All claims shall be submitted on Form DOJ-110 (January, 1980)
-Employee Claim for Loss or Damage to Personal Property," and Form DOJ-110A,
"Schedule of Property." Upon completion of the applicable sections, the
claimant shall forward the original and two copies of the form(s) together
with appropriate supporting evidence to either his/her supervisor or the
official who authorized the use, transfer, etc., of the personal property.
(5) Processing of Claims
The Traffic Management Office at FBIHQ has the responsibility for
processing and adjudicating claims for loss/damage to household goods and
personal effects under the Act. Claims will be submitted on DOJ Forms 110 and
110A to FBIHQ, Attention: Special Agent Transfers and Traffic Management
Unit, Room 1638. Traffic Management Office will process employees'
loss/damage claims and will then file a claim against the carrier to recover
monies due the Government. The following documents MUST be attached to DOJ
Forms 110 and 110A when filing a claim:
applicable).
applicable).
(a) Copy of estimate of repairs/replacement (where
(b) Copy of receipts for repaired/replaced item (where
(c) Copy of Carrier's Descriptive Inventory.
(d) Any other documents or photographs to support
loss/damage as claimed.
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PART
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
19-9 EVIDENCE IN SUPPORT OF CLAIM
The burden of proof as to the loss or damage of personal property
and the value of such property rests with the claimant. The extent of
documentation required in support of a claim shall be determined by the
official authorized to settle claims-. The following documentation should be
provided as a minimum, when _applicable, by the claimant when submitt-ing
his/her claim:
(1) [One]itemized repair[estimate, one estimate]as to the value of
property prior to damage, and/or[one estimate]for replacement cost.
(2) A copy of the document authorizing, assigning, or providing
the location where the personal property was located at the time the loss or
-damage occurred.
(3) Evidence, in those cases where a possibility of recovery
exists against a carrier,[warehouser,]insurer, or other contractor, that a
claim was filed and denied or there was a refusal to pay the claim in full.
The reasons for the denial or refusal to pay in full should be included as
part of this evidence.
(4) Statements of witnesses and/or other persons having personal
knowledge of the facts underlying the claim.
(5) A copy of the travel authorization if personal property was
lost or damaged while in transit aid/or while in temporary storage during, the
transit process.
(6) A power of attorney or other satisfactory evidence of
authority to file when the claim is filed by an agent or legal representative
of the claimant.
[(7) Where a report of loss or damage has been made to local
authorities, the case or report number, date, and identity of the officer to
whom the report was made. Same as to claims made to carriers and insurers.]
19-10 SUPERVISORY REVIEW
The facts and circumstances surrounding the damage to or loss of
the claimant's personal property shall be reviewed by the claimant's
supervisor or the official who requested the use of such personal property.
This individual, if satisfied that the article(s) in question was in fact
reasonable, useful, or proper under the circumstances existing at the time
and place of the incident, and also if in his/her opinion the damage or loss
was not caused by the negligent or wrongful act of the claimant, his/her
agent, dependent or co?worker, then that individual will certify his/her
concurrence on the Form DOJ-110 (January, 1980), or if unsatisfied as to the
bona fides of the claim, official shall indicate his/her nonconcurrence and
forward the claim and all other supporting documentation and justification to
the Administrative Services Division, FBIHQ, for review, evaluation, and
investigation of the claim. Form DOJ-110 and all supporting evidence shall
comprise a claim file.
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SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
19-11 DETERMINING VALUE OF DAMAGED OR LOST PERSONAL PROPERTY
All amounts claimed, recommended, approved or disapproved shall be
computed under the guidelines set forth herein.
(1) Factors for Determination of Compensation ? Compensation
allowable for an item ot personal property shall not exceed the depreciated
value of the item at the time of its damage or loss. Depreciated value shall
be determined by taking into consideration the following factors:
(a) Replacement Cost ? The value of damaged or lost personal
property is primarily based on the replacement cost at the claimant's duty
station at the time of the incident. Replacement cost should be computed on
the basis of a new item which is identical to or substantially similar in
nature to the item which was damaged or lost. However, in no case shall the
replacement cost, within reasonable limits, exceed the original cost of
acquiring the item. In these situations, employees should obtain adequate
insurance coverage to guard against unusual losses. (See 19-4.)
(b) Estimated (Appraised) Value ? If the cost of replacing a
damaged or lost item of personal property cannot be accurately placed because
of the uniqueness or individuality of the item or for other reasons, valuation
may be dictated by qualified, reputable, and credible evidence of value at the
time of the incident. (See 19-12 on items of extraordinary value.)
Appraisals and/or other evidence shall be furnished to ascertain the
credibility, reliability, and impartiality of the claim, the appraisal and the
resulting valuation.
(c) Adjusted Value ? If the value of damaged or lost
personal property cannot be determined by other means, the purchase price, or
value, at the time of acquisition shall be adjusted to reflect the increased
cost of replacing the item resulting from the declining Value of the dollar.
Sufficient information shall be furnished to enable a sound evaluation to be
conducted to arrive at a fair valuation.
(d) Depreciation ? Depreciation represents the decrease in
the value of an item due to wear and tear, natural deterioration,
obsolescence, lack of care, and depletion. The rate of decrease varies by
type of property. Rates of depreciation for various types of property are
found in the Table of Rates of Depreciation.
(e) Salvage ? Salvage value represents that portion of the
cost of personal property that is recovered at the end of its productive life.
Some articles such as typewriters and automobiles are traded in on similar
assets at the end of their useful life. Generally, the salvage values of such
articles are their trade?in values. Ordinarily, other articles of personal
property possess no trade?in value and little or no salvage value but may
possess scrap value for its intrinsic material content. Salvage value will be
based on the most reliable estimates available and shall be included in all
claims where its effect is material.
- Collectibles ? A collectible is any amount due an
individual from an insurance company, carrier, or other person resulting from
damage to or loss of an insured article of personal property, or an article
lost or damaged while under the care of a carrier or other person.
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SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
(g) Cost of Repair ? If the property can be economically
repaired, the allowable compensation is the actual or estimated net cost of
repairs necessary to restore the property to substantially the condition which
existed immediately before the damage. The cost of repairs may be established
by a receipted bill or[one estimatejsigned by reputable dealers or[repairers.1
If the cost of repairs exceeds the depreciated value of the item at the time
of damage, then the depreciated value shall be used as the maximum basis for
compensation. Claims are not -normally payable for fees paid to obtain
estimates of repair (or appraised values) in conjunction with submitting a
claim under this Act. However, where, in the opinion of the approving
officer, the claimant could not obtain an estimate without paying a fee, such
a claim may be considered in an amount reasonable in relation to the value
and/or the cost of repairs of the articles involved, provided that the
evidence furnished clearly indicated that the amount of the fee paid will not
be deducted from the cost of repairs if the work is accomplished by the
estimator.
(h) Depreciated Value ? Depreciated value is that value
which remains after depreciation is applied against the replacement cost,
estimated value, or adjusted value of an item of damaged or lost personal
property. The depreciated value shall be the maximum amount to be awarded in
settlement of a claim filed under the Act.
19-12 . ITEM. OF EXTRAORDINARY VALUE
An item of,extraordinary value is not[totally]compensable under
the Act. An item of extraordinary value is one which because
of[extraordinary]quality of workmanship or design, the high value of materials
it contains, or its association with a past event or period, or historical
figure, possesses a value far beyond the usual value of an item of like
nature. Such an item[includes those articles which primarily serve an
artistic or decorative purpose, or which are collector's items and should be
insured by employees as stated in 19-4. For purposes of this order, an item
of extraordinary value is any single item; i.e., painting, china cabinet, or
set of items such as silverware or china which has a value in excess of
$3,000. Reimbursement for loss or damage to an item of extraordinary value
shall be limited to $3,000.]
[{l9-13 EMERGENCY PARTIAL PAYMENTS
Quite frequently a claimant is in immediate need of funds to
[ replace damaged or destroyed property and avoid unnecessary hardship and
[ inconvenience. An emergency partial payment is authorized under the following
[ circumstances:
(1) A hardship situation must exist;
(2) The total amount claimed is within the monetary jurisdiction
of the approving or settlement authority involved; and
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PART I
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
(3) It is determined that the claim is clearly payable under the
Act, in an amount exceeding the amount of the proposed emergency payment.
Prior to making any advance payment, the authority approving such payment
normally will obtain an executed acceptance agreement from the claimant or
his/her representative in the language and format indicated below:
[ EMERGENCY PARTIAL PAYMENT ACCEPTANCE AGREEMENT
(Date)
[ I, , agree to accept the sum of $ as a partial
[ payment in order to alleviate immediate need and in partial settlement of my
[ claim for (property damage) (property loss) sustained by me as the result of
( an incident on involving a (shipment of household goods) (loss in
[ quarters) .
(other)
I understand that this amount will be deducted from any award made in final
settlement of my claim.
(Claimant's signature)
(Name printed)]
([19-14] INSTRUCTIONS FOR PREPARING FORM DOJ-11O
Complete an original and two copies in accordance With the
instructions in the following paragraphs which are keyed to the form on[a]
following page.
(1) Name of Claimant ? Enter the full name of the claimant. If
the claimant is other than the employee, enter the name of the employee in
parentheses below that of the claimant.
(2) Title of Position ? Enter the position of the employee at the
time the loss or damage occurred.
(3)
Address of Claimant (Include[ZIP]Code) ? Enter the current
mailing address of the claimant.
(4) Office Where Employed/Telephone No. ? Enter the name of the
office (organizational unit) which employed the employee at the time the loss
or damage occurred.
(5) Location of Office (at Time of Incident) ? Enter the name of
city and state where the employee's office was located at the time the loss or
damage occurred.
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PART I \?apY
I claimant.
SECTION-19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
(6) Social Security No. - Enter the social security number of the
(7) Location Where Loss or Damage Occurred - Enter the address of
I the building where the property was located when the loss or damage occurred.
I If the property was in transit, state the point of origin and destination.
(8) Date of Loss Or Damage - Enter the date on which the loss or
damage occurred. If the property was in transit and the date is not known,
indicate the dates on which the property was in transit.
(9) Facts and Circumstances of the Incident - State in detail all
the facts and circumstances under which the loss or damage occurred.
(10) Affirmations and Claimant Certification - Answer in the
appropriate block either "Yes" or "No" for each of the indicated questions.
The claimant shall then sign his/her full signature and date. When signing
this claim, the claimant certifies that he/she is entitled to any payments
made and is aware of penalties for willfully making a fraudulent claim.
(11) Amount of Claim - Enter the sum of the figures from the
amount claimed column of the Schedule of Property (DOJ-110A). From this total
subtract any amount collected or collectible from an insurance company or
carrier to arrive at the total amount claimed.
(12) Supervisory Certification - Have the employee's supervisor or
the cognizant supervisory official who directed the use of the article(s) in
question attest to the validity and propriety of the claim by signing and
dating the claim.
(13) Claims Recommendation - Leave blank. This section is to be
completed by the reviewing official.
(14) Approval of Claim - Leave blank. This section is to be
completed by the settling official.
[ (15-17) Voucher No., Schedule No., Paid by Check No. - Leave blank.
[ To be completed by accounting officials.
[ (18) Accounting Classification - Leave blank. To be completed by
[ accounting officials.
[ NOTE: See sample of Form DOJ-110 which follows.]
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PART I
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
DEPARTMENT OF JUSTICE
EMPLOYEE CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY
(SUBMIT IN TRIPLICATE)
-INSTRUCTIONS TO
To present ? claim for an incident to service Ions pursuant to 31 U.S.O.
240-243. ? request for the payment of. specific stun of money must be
submitted in uniting ithin two (2) yeata of the date of the Incident
Ovine rise to the claim. The two-year period of limitation. being statist-
ory. may not be waived.
Items 1-11 of this faun should be completed fully and signed by the
claimant. Item 12 shall be completed by the official who authorized the
um of the articles for which the claim is subrialttoi. Item 13 shall be
completed by the designated reviewing official. Item 14 shall be tom-
plated by the official authorised to approve payment. Item 11-113 are
removed for accounting use.
If the claim is for loss of, or darnag? to. personas property while being
transported or stored incident to the senice or employment of the
claimant. AU documents 'elating to such transportation or storage. e 4..
the Government BLit of Lading. warehouse Receipt, transfer orders.
.to.. must be attached.
CLAIMANT
You are entitled to claim the following:
a. The reasonable local repair east limo Item is 11.1171001141111Y raspabable.
to such case, ? written emir:nate of repair from ? reliable. disinterested
concern, or. if repairs have been oompleted. ? dined. lionited recniPi
should be attached.
b. The reareanable local replacement price if an item is lost. destroyed,
or not economically repairable. A determent from ? reliable, disinter-
anted concern must be attached attesting to the replacement price of
the same or. substantially similar Item.
e. The reasonable meet of obtaining local estimate? of rapairtrePlans?
meat cost, provided such ertimates can not be obtained 'without cost
and such coos are not refundable upon completion of repairs.
Further instructions or information are prescribed in Order DOJ
2110.23A.
CLAIM IS HEREBY SUBMITTED FOR DAMAGE TO OR LOSS OF PERSONAL PROPERTY INCIDENT TO SERVICE OR EMPLOYMENT
1. N11114 of Claimant
2. Title of Position
3. Address of Claimant (Include Zip Code)
-
_
4. Office Where Employed/Telephone No.
5. Locanon of Office (at Time of Incident)
6. Social Security No.
?
7. Location Where Loss or Damage Occurred
8. Date of Lou or Damage
9. Facts and Circumstances of the Incident (State facts in detail. use additional sheet if necessary.)
10. Affirmarions and Claimant Certification:
-
a. Was the damage or loss for which chins is made caused in whole or in put by any negligence or wrongful act
part, or another employee's part?
b. Have you recovered any of the property Of has any 0( 11 been replaced by the Government?
c. Do you have private insurance?
i If answer toe, is "YES- is all correspondence with your insurer, including* copy of your demand for reimbursement,
d. Has a demand been made against the common carrier or warehouseman involved?
If answer to d. is "YES, is all correspondence with carrier or warehouseman attached, including a copy of the
e. Were any of the claimed items Government property? If answer is "YES", then so indicate on Form D01-110A
f. Was any portion of property claimed, acquired, or held for sale or dispositon by commerical transactions, or for
or business enterprise? ?
g. If any of the property for which C11011 is made is later recovered, I agree to give written notice to the office paying
h. All documents required are attached hereto, and a detailed list of the property is set forth on Form DOJ-110A
made a part of this statement. I have full knowledge of the penalties involved for willfully making a false, fictitious,
(Section 287 of Title 18. U.S.C.. provides a maximum fine of $10,000 or imprisonment for five years or both.)
L ! hereby assign to the United States, to the extent of any payment on this claim accepted by me, all my right,
any claim 1 have against any carrier, insurer, or other party arising out of the above described incident and will,
evidence as may be required to enable the United States to enforce such claim.
j. 1 further authorize the United States to withhold from my pay or accounts for any payments made to me by ?
parry when I am also reimbursed by the United States and for any payments made by the United States In
contained herein which thereafter is determined to be incorrect or untrue. ..
k. I hereby authorize my insurer to release any information to the United States regarding insurance coverage 1 here
L 1 have not made a previous clam against the United States for 1014 or damage now claimed.
IN B. If explanations are necessary, provide same on additional sheet and attach hereto.)
on your part, your agent's
attached?
demand for reimbursement?
(Schedule of Property).
use in a private profession
this claim.
(Schedule of Property) and
or fraudulent claim.
?
title, and interest In and to
upon request, furnish such
carrier. insurer. or other
reliance on the information
.
for this iota.
YES
NO
11. f AmounFt of
rom orm
Amount of
Lem Insurance
tie Collectible
Total Amount
D0.1.11 Gann Il0A)Un .S. Money Taken

LoesiDamage
Collected
?
Claimed
Sirnarure of Claimant 0 . ta
PREVIOUS EDIT:OHS ?_13301.ETE
Form D0.1-110 January 1960
222.03
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k4n,di
PART I
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
12. Supervisory Certification: 1 cm:if), that the article(s) in question was reasonable. useful and proper under the circUMM.11103*. and also to the ben of my know-
ledge the damage or loss was not due to a negligent or wrongful act of the claimant, hiaTher agent, dependent or co-worker.
Signature:
Name Title Date
13. Claims Recommendation:
This claim has been reviewed, evaluatni, and huestigated, and is forwarded herewith together with supporting
On the basis of such examinations which were deemed necessary under the circumstances surrounding the clains,
as follows: .
papers marked Exhibits through
the claim Ls nicOrninended foe anal settlement
Date Claim ReceivedAmount
Disapproved 0
Approved 0
Orpnuatton .
Typed Name of Claims Officer
Signature of Claims Officer and Date
14. Approval of Claim:
0 After due consideration 1 have determined that this claim is meritorious and is cognizable under 31 U.S.C. 241: the claimant is, proper claimant; and an
awazd of $ isapproved.
0 After due consideration I have decided to disapprove the claim foe the following reason(s):
-
I
,
Yyped Name of Approving Authotiry
Signature and Date
DATA REQUIRED BY THE PRIVACY ACT OF 1974
(S U.S.C. 552a)
AUTHORITY: 31 U.S.C. 240-243 and 951-953
PRINCIPAL PURPOSE: Filing, Mvustigation, proceenng and settlement of claims
ROUTINE US5...S:
a: Information us principally used to provide a legal buts for administrative payment of claim against the Government. Information Is a/so used In connection sititlt:
(I) Recovery from common carriers warehousemen. other third parties or their Insurers for damage. Ions or destruction of persona/ property of empioyua
while in transit or storage at Government expense.
(2)Collection from claimant of Improper payment or overpayment.
(3) Investigation of posaible fraudulent claim.
(4) Possible criminal prosecution by the Department of .lustIce If fraud Is established..
b. SSN is used to insure correct Identification of claimants as this is th? only means of Insuring payment to proper clalinent and to avoid payment of duplicate
claims. -
'MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Dtsclouir? of information le voluntary.
Failure to supply information in subet?ntlation of claim will cat.* delay In settlement and may result In denial of a portion or all of th? claim.
15. Voucher No.
?
16. Schedule No.
17. Paid by Chock No.
IS. Accountir Classtilcaton
4/15./81 t1AOP
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PART I
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
[[19-15] INSTRUCTIONS FOR PREPARING FORM DOJ-110A
Complete an original and one copy in accordance with the
instructions in the following paragraphs which are keyed to the form.
(1) Claimant - Enter the full name of the claimant. If the
claimant is other than the employee, enter the name of the employee in
parentheses below that of the claimant.
(2) Page of - Consecutively number each page of the Schedule of
Property. Indicate the total number of pages comprising the schedule. This
information will ensure that all pages are accounted for.
(3) Line Number - Consecutively number each article listed.
(4) Description of Article - Enter the name of the article. If
known, also enter the brand, manufacturer and model, serial or ID number, or
other information available to more specifically describe the article. For
claims regarding household goods, include inventory item number as listed on
carriers' Household Goods Descriptive Inventory.
(5) Nature and Extent of Damage
(a) Describe the nature and extent of damage received by
each damaged article listed.
(b) Insert the word "missing" next to each lost article
listed.
(6) Date of Purchase or Acquisition - Enter the month and year of
purchase or acquisition. When the month is unknown, enter June. When the
exact year is unknown, enter the best estimate.
(7) Value of Item/Basis - Enter the value of the lost or damaged
article of personal property less applicable salvage value. The value of the
item shall be based upon either the replacement cost, the estimated value as
supported by appraisals, or the original purchase price if known. The basis
upon which the article is valued should be indicated by inserting after the
value either an "R" for replacement cost, "E" for estimated value, or "0" for
original purchase price.
(8) Depreciation (Rate)
utilized by the adjudicating officer.
(9)
utilized by the adjudicating officer.
(10)
utilized by the adjudicating officer.
- Leave blank. This column to be
Depreciation Amount -
Leave blank. This column to be
Maximum Amount Allowable - Leave blank.
222.05
10/30/84
This column to be
MAOP
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PART I.
SECTION 19. EMPLOYEE CLAIMS FOR LOSS OR DAMAGE TO PERSONAL
PROPERTY
(11) Cost of Repairs ? Enter the cost of repairing a damaged item
of personal property as supported by a receipted bill or estimate signed by a
reputable dealer. If the item is missing, then insert an "N/A" in this
column-to indicate that this step is not applicable.
(12) Amount Claimed. Enter the amount which is claimed.
(13) and (14) Reserved for Reviewing Official. Leave blank.
[ These columns are to be utilized by the reviewing officials.
[ NOTE: See sample of Form DOJ-110A which follows.
222.06
12/27/82
MAOP
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R.)
t,)
t?.)
'V ?
CO ????.1
0Ri
Declassified and Approved For Release 2014/04/10: CIA-RDP90-00530R000701780020-2
US. De primmest of Janice Schedule of Property
. ..
. .
Cum..'
0
Page of Pains
Line
.No.
Dercriptenn of AnKi.
ilerlwde ilfd I mark. Pose some. moist eel"
efre?eeforrurt ??% Ilse)
Nature end Exteni of ?mate
(Deseriee la feted be., damaget fl lo?.
mutest murvoi)
Dat f
e o
Purchare or
Acquisition
(Moeohloror)
Value
of Item
(Lem Jabot,
or sew)
Depreciation
(oer
S
lable)
Accumulated
Amount
Maximum
Amount
Allowable
(Deoreesote1
refire)
Coil of
a""'"
""unt
Claimed
Reserved
Amount
Allowed
for Re?iswing Official.
Remarks
_
0
0
?
.0
(ED
?
0
(cD
0
0
_
?
?
?
I
- .
?
.
.
,
_
- -
?
.
PREVIOUS ELIMONS OBSOLETE RAM DOI,.
Mu,,'
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[VOTT-f0C
CLAIMS FOR LOSS OR DAMAGE TO PEFSONAL