§ 114.104 What evidence and information may SBA require relating to my claim? ( a ) For a claim based on injury to or loss of property: ( 1 ) Proof you own the property.
( 2 ) A specific statement of the damage you claim with respect to each item of property.
( 3 ) Itemized receipts for payment for necessary repairs or itemized written estimates of the cost of such repairs.
( 4 ) A statement listing date of purchase, purchase price and salvage value, where repair is not economical.
( 5 ) Full information about potential insurance coverage and any insurance claims or payments relating to your claim.
( 6 ) Any other information that may be relevant to the government's alleged liability or the damages you claim.
( b ) For a claim based on personal injury, including pain and suffering: ( 1 ) A written report from your health care provider stating the nature and extent of your injury and treatment, the degree of your temporary or permanent disability, your prognosis, period of hospitalization, and any diminished earning capacity.
( 2 ) A written report following a physical, dental or mental examination of you by a physician employed by SBA or another Federal Agency. If you want a copy of this report, you must request it in writing, furnish SBA with the written report of your health care provider, if SBA requests it, and make or agree to make available to SBA any other medical reports relevant to your claim.
( 3 ) Itemized bills for medical, dental and hospital expenses you have incurred, or itemized receipts of payment for these expenses.
( 4 ) Your health care provider's written statement of the expected expenses related to any necessary future treatment.
( 5 ) A statement from your employer showing actual time lost from employment, whether you are a full or part-time employee, and the wages or salary you actually lost.
( 6 ) Documentary evidence showing the amount of earnings you actually lost if you are self-employed.
( 7 ) Information about the existence of insurance coverage and any insurance claims or payments relating to the claim in question.
( 8 ) Any other information that may be relevant to the government's alleged liability or the damages you claim.
( c ) For a claim based on death: ( 1 ) An authenticated death certificate or other competent evidence showing cause of death, date of death, and age of the decedent.
( 2 ) Evidence of decedent's employment or occupation at the time of death, including monthly or yearly salary or earnings, and the duration of such 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 his or her death.
( 4 ) Evidence of the support provided by the decedent to each dependent survivor at the time of his or her death.
( 5 ) A summary of the decedent's general physical and mental condition before death.
( 6 ) Itemized bills or receipts for payments for medical and burial expenses.
( 7 ) For pain and suffering damage claims, a physician's detailed statement specifying the injuries suffered, the 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 information that may be relevant to the government's alleged liability or the damages claimed.