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Get GSA SF 91 2020-2022

MOTOR VEHICLE ACCIDENT REPORT Please read the Privacy Act Statement on Page 3 INSTRUCTIONS Sections I through IX are filled out by the vehicle operator. SECTION XII - ATTACHMENTS 87. LIST ALL ATTACHMENTS TO THIS REPORT 88. REVIEWING OFFICIAL S COMMENTS SECTION XIII - COMMENTS/APPROVALS 89. ACCIDENT INVESTIGATOR a. SIGNATURE 90. ACCIDENT REVIEWING OFFICIAL b. DATE c. NAME First middle last d. TRANSPORTED TO a. NAME OF STREET OR HIGHWAY 47. Pedestrian b. DIRECTION OF PEDESTRIAN SW corner to NW corner etc. FROM TO c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT crossing intersection with signal against signal diagonally in roadway playing walking hitchhiking etc. NSN 7540-00-634-4041 Previous edition not usable STANDARD FORM 91 2/2004 Prescribed by GSA-FMR 102-34. 295 SECTION IV - ACCIDENT TIME AND LOCATION Use section VII if additional space is needed. 48. DATE OF ACCIDENT 49. ITEM DAMAGED 64c. HOME TELEPHONE NUMBER 67. LOCATION OF DAMAGED ITEM 65c. POLICY NUMBER 68. ESTIMATED COST SECTION VII - POLICE INFORMATION 69a. NAME OF POLICE OFFICER 69b. BADGE NUMBER 70. PRECINCT OR HEADQUARTERS 71a. PERSON CHARGED WITH ACCIDENT 71b. VIOLATION S SECTION VIII - EXTRA DETAILS SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED CONTINUE ITEMS ON PLAIN BOND PAPER. PRIVACY ACT STATEMENT The information on this form is subject to the Privacy Act of 1974 5 U.S.C. BADGE NUMBER 70. PRECINCT OR HEADQUARTERS 71a. PERSON CHARGED WITH ACCIDENT 71b. VIOLATION S SECTION VIII - EXTRA DETAILS SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED CONTINUE ITEMS ON PLAIN BOND PAPER. PRIVACY ACT STATEMENT The information on this form is subject to the Privacy Act of 1974 5 U.S.C. section 552a. Authority to collect the information is Title 40 U.S.C. Section 491 and the title 31 U.S.C. Routine uses of the collected information may include disclosures to appropriate Federal State or local agencies or contractors when relevant to civil criminal or regulatory investigations or prosecutions the Office of personnel Management and the General Accounting Office for program evaluation purposes a Member of Congress or staff in response to a request for assistance by the individual of record another Federal agency including the Department of Treasury and Justice or a court under judicial proceedings agency Inspectors General in conducting audits private insurance and the collection agencies including agencies under contract to Treasury to collect debt and to other agency finance offices for federal management and debt collection. Furnishing the requested information is mandatory including the Social security Number or Taxpayer s Identification Number TIN for use as a unique identifier to ensure accurate identification for individuals or firms in the system. I certify that the information on this form Sections I thru VII is correct to the best of my knowledge and belief. 72a. NAME AND TITLE OF DRIVER 72b. DRIVER S SIGNATURE AND DATE SECTION X - DETAILS OF TRIP DURING WHICH ACCIDENT OCCURRED 73. ORIGIN 74. NAME last first middle 28. SEX 29. DATE OF BIRTH 30. ADDRESS A 31. MARK X IN TWO APPROPRIATE BOXES KILLED DRIVER PASSENGER INJURED HELPER PEDESTRIAN 35. TRANSPORTED BY 32. IN WHICH VEHICLE 33. LOCATION IN VEHICLE 34. FIRST AID GIVEN BY FED OTHER 2 B 46. TRANSPORTED TO a. NAME OF STREET OR HIGHWAY 47. Pedestrian b. DIRECTION OF PEDESTRIAN SW corner to NW corner etc. FROM TO c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT crossing intersection with signal against signal diagonally in roadway playing walking hitchhiking etc. NSN 7540-00-634-4041 Previous edition not usable STANDARD FORM 91 2/2004 Prescribed by GSA-FMR 102-34. Section 7701. The formation is required by federal Government agencies to administer motor vehicle programs including maintaining records on accidents involving privately owned and Federal fleet vehicles and collecting accident claims resulting from accidents. Federal employees and employees under contract will use the information only in the performance of their official duties. Routine uses of the collected information may include disclosures to appropriate Federal State or local agencies or contractors when relevant to civil criminal or regulatory investigations or prosecutions the Office of personnel Management and the General Accounting Office for program evaluation purposes a Member of Congress or staff in response to a request for assistance by the individual of record another Federal agency including the Department of Treasury and Justice or a court under judicial proceedings agency Inspectors General in conducting audits private insurance and the collection agencies including agencies under contract to Treasury to collect debt and to other agency finance offices for federal management and debt collection. Furnishing the requested information is mandatory including the Social security Number or Taxpayer s Identification Number TIN for use as a unique identifier to ensure accurate identification for individuals or firms in the system. I certify that the information on this form Sections I thru VII is correct to the best of my knowledge and belief. 72a. NAME AND TITLE OF DRIVER 72b.

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