CLAIM FOR LOSS OF OR DAMAGE TO PERSONAL PROPERTY INCIDENT TO SERVICE

PART I - TO BE COMPLETED BY CLAIMANT (See back for Privacy Act Statement and Instructions.)

 1. NAME OF CLAIMANT (Last, First, Middle Initial)

 

2. BRANCH OF SERVICE 3. RANK OR GRADE 4. SOCIAL SECURITY NUMBER

 5. HOME ADDRESS (Street, City, State and Zip Code) 6. CURRENT MILITARY DUTY ADDRESS (If applicable) (Street, City, 

 State and Zip Code)

 7. HOME TELEPHONE NO. (Include area code) 8. DUTY TELEPHONE NO. (Include area code) 9. AMOUNT CLAIMED

10. CIRCUMSTANCES OF LOSS OR DAMAGE (Explain in detail. Include date, place, and all relevant facts. Use additional sheets if necessary.)

11. DID YOU HAVE PRIVATE INSURANCE COVERING YOUR PROPERTY? (E.g., say "Yes" on a shipment or quarters claim if you 

 had transit, renter's or homeowner's insurance; say "Yes" on a vehicle claim if you had vehicle insurance. Attach a copy of

 your policy.)

YES NO

12. HAVE YOU MADE A CLAIM AGAINST YOUR PRIVATE INSURER? (If "Yes," attach a copy of your correspondence. If you

 have insurance covering your loss, you must submit a demand before you submit a claim against the Government.)

13. HAS A CARRIER OR WAREHOUSE FIRM INVOLVED PAID YOU OR REPAIRED ANY OF YOUR PROPERTY? (If "Yes," attach 

 a copy of your correspondence with the carrier or warehouse firm.)

14. DID ANY OF THE CLAIMED ITEMS BELONG TO THE GOVERNMENT OR TO SOMEONE OTHER THAN YOU OR YOUR 

 FAMILY MEMBER? (If "Yes," indicate this on your "List of Property and Claims Analysis Chart," DD Form 1844.)

15. WERE ANY OF THE CLAIMED ITEMS ACQUIRED OR HELD FOR SALE, OR ACQUIRED OR USED IN A PRIVATE PROFESSION

 OR BUSINESS? (If "Yes," indicate this on your "List of Property and Claims Analysis Chart," DD Form 1844.)

16. UNDER PENALTY OF LAW, I DECLARE THE FOLLOWING AS PART OF SUBMITTING MY CLAIM:

 If any missing items for which I am claiming are recovered, I will notify the office paying this claim. (For shipment claims.) Missing items

were packed by the carrier; they were owned prior to shipment but not delivered at destination; after my property was packed, I/my agent

checked all rooms in my dwelling to make sure nothing was left behind.

 I assign to the United States any right or interest I have against a carrier, insurer, or other person for the incident for which I am claiming; I

authorize my insurance company to release information concerning my insurance coverage.

 I authorize the United States to withhold from my pay or accounts for any payments made to me by a carrier, insurer, or other person to

the extent I am paid on this claim, and for any payment made on this claim in reliance on information which is determined to be incorrect or

untrue. I have not made any other claim against the United States for the incident for which I am claiming. I understand that if any

information I provide as part of my claim is false, I can be prosecuted.

17. SIGNATURE OF CLAIMANT (or designated agent) 18. DATE SIGNED

 (YYYYMMDD)

PART II - CLAIMS APPROVAL (To be completed by Claims Office)

19. PROCEDURE (X one)

a. SMALL CLAIMS

b. REGULAR CLAIMS

$

21. SIGNATURES (Signatures at a and c not required if small claims procedure is utilized)

 a. CLAIMS EXAMINER b. DATE SIGNED

 (YYYYMMDD)

c. REVIEWING AUTHORITY d. DATE SIGNED

 (YYYYMMDD)

 e. TYPED NAME AND GRADE OF APPROVING AUTHORITY f. SIGNATURE OF APPROVING AUTHORITY g. DATE SIGNED

 (YYYYMMDD)

DD FORM 1842, MAY 2000 PREVIOUS EDITION IS OBSOLETE.

20. AMOUNT AWARDED. The claim is cognizable and meritorious under 31 U.S.C. 3721;

 the claimant is a proper claimant; the property is reasonable and useful; the loss has 

 been verified in accordance with applicable procedures as prescribed by the controlling

 departmental regulation; and the following award is substantiated:
PRIVACY ACT STATEMENT

AUTHORITY: 31 U.S.C. 3721, and EO 9397, November 1943 (SSN).

PRINCIPAL PURPOSE(S): Filing, investigation, processing and settlement of claims for losses incident to service.

ROUTINE USES:

a. Information is principally used to provide a legal basis for the administrative payment of claims against the Government. 

Information is also used in connection with:

(1) Recovery from common carriers, warehouse firms, insurers and other third parties.

(2) Collection from claimants of improper payments or overpayments.

(3) Investigation of possible fraudulent claims.

(4) Possible criminal prosecution by the Department of Justice or other agencies if fraud is established.

b. Social Security Numbers are used to assure correct identification of claimants in order to assure payment to the proper

claimant and avoid duplication of claims.

DISCLOSURE: Voluntary; however, failure to supply information will cause delay in settlement and may result in denial of a

portion or all of the claim.

INSTRUCTIONS TO CLAIMANTS

1. You must submit your claim in writing within two

years of the date of the incident giving rise to the claim. 

This two year time limitation may not be waived.

2. The claimant or an authorized agent must complete

and sign Part I of this form, answering all questions. If

the claim is signed by an agent (such as a spouse) or a

survivor of a deceased proper claimant, that person must

have a document showing his or her authority to present

the claim, such as a power of attorney, etc.

3. If the claim is for property lost or damaged while being

shipped or stored pursuant to travel orders, submit copies

of your orders and all shipping documents, including your

inventory and your "Joint Statement of Loss or Damage

at Delivery/Notice of Loss or Damage," DD Forms

1840/1840R. If you notice damage after delivery, you

must complete the DD Form 1840R and get it to the

Claims Office within 70 days after delivery.

4. You may obtain further information from a Claims

Office.

5. You are entitled to claim the following:

 a. Reasonable local repair cost, if an item can be

economically repaired. (You may claim small amounts

without an estimate. Otherwise, submit an estimate of

repair from a repair firm or, if repairs have been

completed, your receipt. The claims office may waive

this in appropriate cases.)

 b. Reasonable local replacement cost if an item is

missing, destroyed, or not economic to repair.

(Replacement costs may be obtained from commercial

catalogs or a military exchange. If you cannot find the

item in a catalog or the exchange and the cost is more

than $100.00, obtain a statement from a commercial firm

for the cost of a similar item. If you have purchase

receipts, bring these to the Claims Office as well.)

 c. Reasonable cost of obtaining local estimates of

repair, if the cost of such estimates will not be credited if

repair work is done. (Normally, you may not claim

appraisal fees.)

PART III - DENIAL OR SUPPLEMENTAL PAYMENT (To be completed by Claims Office)

23. DENIAL (X if applicable)

 The claim is not cognizable or meritorious under 31 U.S.C.

3721 and the applicable provisions of the controlling

departmental regulation, and is denied.

24. SUPPLEMENTAL PAYMENT (X and complete if applicable)

 The claim is cognizable and meritorious

under 31 U.S.C. 3721, and the following

additional award is substantiated:

$

26. APPROVING/SETTLEMENT AUTHORITY (Settlement Authority is required for denial.)

25. SIGNATURES 

DD FORM 1842 (BACK), MAY 2000

 a. CLAIMS EXAMINER b. DATE SIGNED

 (YYYYMMDD)

c. REVIEWING AUTHORITY d. DATE SIGNED

 (YYYYMMDD)

 a. TYPED NAME b. SIGNATURE c. DATE SIGNED

 (YYYYMMDD)

b. GRADE