Submitting Payment Information

U.S. Department of Homeland Security

Claims, Outreach, and Debt Branch

601 South 12^th Street, TSA-9

Arlington, VA 20598-6009

TODAY.DATE

CLAIMANT.COMPANY

CLAIMANT.TITLE CLAIMANT.FIRST_NAME CLAIMANT.LAST_NAME

CLAIMANT.ADDRESS1

CLAIMANT.ADDRESS2

CLAIMANT.CITY, CLAIMANT.STATE CLAIMANT.ZIP

CLAIMANT.COUNTRY

Re: TSA Control Number: CLAIM.CLAIM_NUMBER

Dear CLAIMANT.TITLE CLAIMANT.FIRST_NAME CLAIMANT.LAST_NAME:

Your claim against the United States in the amount of $CLAIM.CLAIM_AMOUNT has been granted in full.

Under the Federal Tort Claims Act (FTCA), this decision constitutes final administrative action on your claim. Once you complete and return the enclosed form, your acceptance of this offer will be final and conclusive. This will also waive your right to seek any additional payment on your claim from the Transportation Security Administration (TSA) and its employees or any other part of the United States government.

If we do not receive your response within 90 days, we will presume that you have rejected the offer and deny your claim. To receive payment, please fill out the attached form and return it to TSA by:

Mail: Claims, Outreach, and Debt Branch – TSA-9

ATTN: CLAIM.CLAIM_NUMBER – APPROVAL

Transportation Security Administration

601 South 12^th Street

Arlington, Virginia 20598-6009

Fax: For faster service, please fax to: (703) 603-4092

Should you have any questions, you may reach the Claims, Outreach, and Debt Branch at (571) 227-1300 or by e-mail at TSAClaimsOffice@tsa.dhs.gov.

Yours sincerely,

Kimberly J Davis

Assistant Director, Management Services and Claims

Financial Management Division

TSA Office of Finance and Administration

Enclosure

ATTACHMENT TO FTCA CLAIM APPROVAL LETTER

CLAIM.CLAIM_NUMBER - CLAIMANT.LAST_NAME - $CLAIM.CLAIM_AMOUNT

In order to process your claim for payment, please mail this completed form to the address on your approval letter. For faster processing, please fax this form to: (703) 603-4092.

Payee Social Security Number or other taxpayer identification number: ____________________

Payee Name or Company: _________________________________________________________

Address (P.O. Boxes are not accepted): _______________________________________________

City: _______________________State: ______ Zip: ___________ Country: ________________

NOTICE: You are accepting the offered payment in full satisfaction and release of all claims relating to the incident from which your claim arose. If your claim is governed by California law, you waive the protec­tions of Calif. Civ. Code § 1542. I and my guardians, heirs, executors, administrators, and assigns (“I”) agree to and do accept this settlement in full settlement and satis­faction and release of any and all claims, demands, rights, and causes of action of any kind, whether known or unknown, includ­ing without limita­tion any claims for fees, costs, expenses, survival, or wrongful death, arising from any and all known or unknown, foreseen or unfore­seen bodily injuries, personal injuries, death, or damage to property, which I may have or hereafter acquire against the United States of America, its agents, servants, or em­ployees, on account of the subject matter of My administrative claim, or that relate or pertain to or arise from, directly or indi­rectly, the subject matter of My administrative claim. I further agree to reimburse, indemnify, and hold harmless the United States of America, its agents, servants, and employ­ees, from and against any and all claims, demands, rights, and causes of action of any kind, whether known or unknown, including without limitation claims for subrogation, indemnity, contribution, or lien of any kind, or for fees, costs, expenses, survival or wrongful death that relate or pertain to or arise from, directly or indirectly, any act or omission that relates to the subject mat­ter of My administrative claim.

I acknowledge that I am acting in my capacity as the claimant; as the claimant’s duly authorized agent; or as the claimant’s legal representative.

Authorized Signature: ____________________________________ Date: _________________

Payment Method:

• I request a check mailed to the address above. (You will receive a check from the U.S. Treasury)

• I request payment by electronic funds transfer into the following account: (Deposit will be from the U.S. Treasury. Deposit code will show as USCG Treas or CGVA.) Option for U.S. bank payments only - any errors or omissions in the banking information below may result in your payment being mailed to the above address. Bank account must be in the claimant’s (or guardian) name.

Payee Account Name:	U.S. Bank Name:
U.S. Routing Number/ABA Bank # (9 digits):	U.S. Bank Address:
Payee Account #:
Check One: Checking Account Savings Account

PRIVACY ACT STATEMENT AND PAPERWORK REDUCTION ACT STATEMENT

AUTHORITY: 31 U.S.C. 3325(d); 31 U.S.C. 3332. PRINCIPAL PURPOSE(S): This information will be used to remit payment of your claim. ROUTINE USE(S): The information you provide, including your social security number, will be disclosed to the U.S. Treasury Department to determine whether you have any outstanding debts to the government that should be paid from your settlement and may also be disclosed to other Federal agencies in order to process your claim, or for other routine uses listed in the applicable system of records notices. DISCLOSURE: Voluntary; failure to furnish the requested information may result in a delay or denial of payment on your claim. Failure to provide you SSN to taxpayer identifying number may result in a delay of payment of your claim.

Paperwork Reduction Act Statement of Public Burden: TSA is collecting this information because a determination has been made regarding your tort claim against the agency that payment is warranted; therefore, TSA needs certain information to facilitate payment. The public burden for this collection of information is estimated to be approximately 30 minutes. This is a voluntary collection of information; however, failure to provide this information may delay or hinder the processing of your claim payment. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0039, which expires 01/31/2019

www.TSA.gov

File 1000.15.1

CMB 5-1-9