§ 793.4 Administrative claims; 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 the cause of death, date of death, and age of the decedent.
( 2 ) Decedent's employment or occupation at the 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, birthdates, kinship, and marital status of the decedent's survivors, including 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 or payments for such expenses.
( 7 ) If damages for pain and suffering before 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 the responsibility of the United States for the death or the damages claimed.
( b ) *Personal injury.* In support of a claim based on personal injury, 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 the 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 and/or mental examination by a physician employed or designated by the National Credit Union Administration. A copy or 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 National Credit Union Administration any other physician's reports previously or thereafter made of the physical or mental condition which is the subject 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 his 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 the responsibility of the United States for the personal injury or the damages claimed.
( c ) *Property damage.* In support of a claim for damages to or loss of property, real or personal, the claimant may be required to submit the following information or evidence: ( 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 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 for a determination of his claim within 3 months after a request therefore has been mailed to his last known address may be deemed an abandonment of the claim. The claim may be thereupon disallowed.
[37 FR 5928, Mar. 23, 1972, as amended at 75 FR 34623, June 18, 2010]