**§14.616 Form and place of filing claim.**

\(a\) *Form of claim.* Claims arising under 38 U.S.C. 515(b) will be
prepared in the form of a sworn statement and submitted in duplicate.
The original copy of the claim will be sworn to or affirmed before an
official with authority to administer oaths or affirmations and will
contain the following information, at least:

\(1\) The name and address of claimant;

\(2\) The amount claimed for injury or death, and for property loss or
damage;

\(3\) If property was lost or damaged, the amount paid or payable by the
insurer together with the name of the insurer;

\(4\) A detailed statement of the facts and circumstances giving rise to
the claim, including the time, place, and date of the accident or
incident;

\(5\) If property was involved. a description of the property and the
nature and extent of the damage and the cost of repair or replacement
based upon at least two impartial estimates;

\(6\) If personal injury was involved, the nature of the injury, the
cost of medical and/or hospital services, and time and income lost due
to the injury;

\(7\) If death is involved, the names and ages of claimants and their
relationship to decedent;

\(8\) The name and official position of the employee of the United
States allegedly responsible for the accident or injury, or loss or
damage of property;

\(9\) The names and addresses of any witnesses to accident or incident;
and

\(10\) If desired, the law applicable to the claim.

\(b\) *Place of filing claim.* Claims arising in the Philippines under
38 U.S.C. 515(b) will be filed with the Director, Department of Veterans
Affairs Regional Office, Manila, Republic of the Philippines. Claims
arising in other foreign countries will be filed with the American
Embassy or Consulate nearest the place where the incident giving rise to
the claim took place.

\(c\) *Evidence to be submitted by claimant.*

\(1\) *General.* The amount claimed on account of damage to or loss of
property or on account of personal injury or death shall, so far as
possible, be substantiated by competent evidence. Supporting statements,
estimates and the like will, if possible, be obtained from disinterested
parties. All evidence will be submitted in duplicate. Original evidence
or certified copies shall be attached to the original copy of the claim,
and simple copies shall be attached to the other copy of the claim. All
documents in other than the English language will be accompanied by
English translations.

\(2\) *Personal injury or death.* In support of claims for personal
injury or death, the claimant will submit, as may be appropriate,
itemized bills for medical, hospital, or burial expenses actually
incurred; a statement from the claimant's or decedent's employer as to
time and income lost from work; and a written report by the attending
physician with respect to the nature and extent of the injury, the
nature and extent of treatment, the degree of disability, the period of
hospitalization or incapacitation, and the prognosis as to future
treatment, hospitalization and the like.

\(3\) *Damage to personal property.* In support of claims for damage to
personal property which has been repaired, the claimant will submit an
itemized receipt, or, if not repaired, itemized estimates of the cost of
repairs by two reliable parties who specialize in such work. If the
property is not economically repairable, the claimant will submit
corroborative statements of two reliable, qualified persons with respect
to cost, age of the property and salvage value.

\(4\) *Damage to real property.* In support of claims for damage to
land, trees, buildings, fences, or other improvements to real property,
the claimant will submit an itemized receipt if repairs have been made,
or, if repairs have not been made, itemized estimates of the cost of
repairs by two reliable persons who specialize in such work. If the
property is not economically repairable, the claimant will submit
corroborative statements of two reliable, qualified persons with respect
to the value of the improvements both before and after the accident or
incident and the cost of replacements.

\(5\) *Damage to crops.* In support of claims for damage to crops, the
claimant will submit an itemized signed statement showing the number of
acres, or other unit measure of crop damaged, the probable yield per
unit, the gross amount which would have been realized from such probable
yield and an estimate of the costs of cultivating, harvesting and
marketing the crop. If the crop is one which need not be planted each
year, the diminution in value of the land beyond the damage to the
current year's crop will also be stated. (Approved by the Office of
Management and Budget under control number 2900-0437)

\[38 FR 5474, Mar. 1, 1973, as amended at 42 FR 41418, Aug. 17, 1977; 49
FR 32848, Aug. 17, 1984\]