§ 35.4 Administrative claim; evidence and information to be submitted. ( a ) *Death.* In support of a claim based on death, the claimant may be required to submit the following evidence or information: ( 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 monthly or yearly salary or earnings (if any), and the duration of his 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 for support upon the decedent at the time of his death.
( 4 ) Degree of support afforded by the decedent to each survivor dependent upon him for support at the time of his 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 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 which may have a bearing on either the responsibility of the United States for the death or the damages claimed.
( b ) *Personal injury.* In support of a claim for personal injury, including pain and suffering, the claimant may be required to submit the following evidence or information: ( 1 ) A written report by his attending physician or dentist setting forth the nature and extent of the injury, nature and extent of treatment, any degree of temporary or permanent disability, the prognosis, period of hospitalization, and any diminished earning capacity. In addition, the claimant may be required to submit to a physical or mental examination by a physician employed or designated by the Department. A copy of the report of the examining physician shall be made available to the claimant upon the claimant's written request provided that claimant has, upon request, furnished the report referred to in the first sentence of this paragraph and has made or agrees to make available to the Department any other physician's reports previously or thereafter made of the physical or mental condition which is the subject matter of his claim.
( 2 ) Itemized bills for medical, dental, and hospital expenses incurred, or itemized receipts of payment for such expenses.
( 3 ) If the prognosis reveals the necessity for future treatment, a statement of expected duration of and expenses for such treatment.
( 4 ) If a claim is made for loss of time from employment, a written statement from his employer showing actual time lost from employment, whether he is a full or part-time employee, and wages or salary actually lost.
( 5 ) If a claim is made for loss of income and the claimant is self-employed, documentary evidence showing the amount of earnings actually lost.
( 6 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the personal injury or the damages claimed.
( c ) *Property damage.* In support of a claim for damage to or loss of property, real or personal, the claimant may be required to submit the following evidence or information: ( 1 ) Proof of ownership.
( 2 ) A detailed statement of the amount claimed with respect to each item of property.
( 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 which may have a bearing either on the responsibility of the United States for the injury to or loss of property or the damages claimed.
( d ) *Time limit.* All evidence required to be submitted by this section shall be furnished by the claimant within a reasonable time. Failure of a claimant to furnish evidence necessary to a determination of his claim within three months after a request therefor has been mailed to his last known address may be deemed an abandonment of the claim. The claim may be thereupon disallowed.