429.104—What evidence do I need to submit with my claim?
(a) Property damage.
To support a claim for property damage, either real or personal, you may be required to submit the following evidence or information:
(3)
An itemized receipt of payment for necessary repairs or itemized written estimates of the cost of such repairs.
(4)
A statement listing date of purchase, purchase price, market value of the property as of date of damage, and salvage value, where repair is not economical.
(5)
Any other evidence or information that may have a bearing either on the responsibility of the United States for the injury to or loss of property or the damages claimed.
(b) Personal injury.
To support a claim for personal injury, including pain and suffering, you may be required to submit the following evidence or information:
(1)
A written report from your attending physician or dentist setting forth the nature and extent of your injury, nature and extent of treatment, any degree of temporary or permanent disability, your prognosis, period of hospitalization, and any diminished earning capacity. You may also be required to submit to a physical or mental examination by a physician employed or designated by SSA. If you submit a written request, we will provide you with a copy of the report of the examining physician provided you agree to make available to SSA any other physician's reports made of the physical or mental condition that is the subject of your claim.
(2)
Itemized bills for medical, dental, and hospital expenses incurred, or itemized receipts of payment for such expenses.
(3)
If your prognosis reveals that you will need future treatment, a statement of expected duration of and expenses for such treatment.
(4)
If you claim a loss of time from employment, a written statement from your employer showing actual time lost from employment, whether you are a full or part-time employee, and wages or salary you actually lost.
(5)
If you claim a loss of income and are self-employed, documentary evidence showing the amount of earnings you actually lost. For example, we may use income tax returns for several years prior to the injury in question and the year in which the injury occurred to indicate or measure lost income. A statement of how much it cost you to hire someone to do the same work you were doing at the time of the injury might also be used in measuring lost income.
(6)
Any other evidence or information that may have a bearing on either the responsibility of the United States for the personal injury or the damages claimed.
(1)
An authenticated death certificate or other believable documentation showing cause of death, date of death, and age at the time of death.
(2)
The decedent's employment or occupation at time of death, including monthly or yearly salary or earnings (if any), and the duration of last employment or occupation.
(3)
Full names, addresses, birth dates, kinship, and marital status of the decedent's survivors, including identification of those survivors who were dependent upon the decedent for support at the time of death.
(4)
Degree of support the decedent provided to each survivor dependent on the decedent for support at the time of death.
(6)
Itemized bills for medical and burial expenses incurred, or itemized receipts of payments for such expenses.
(7)
If damages for pain and suffering prior to 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 injury and death.
(8)
Any other evidence or information that may have a bearing on either the responsibility of the United States for the death or the damages claimed.
(d) Time limit for submitting evidence.
You must furnish all the evidence required by this section within a reasonable time. If you fail to furnish all the evidence necessary to determine your claim within 60 days after being asked to do so, we may find that you have decided to abandon your claim.