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A worked example or template for presenting a claim for damage, injury or death to a federal agency. Use it to understand the fields, examples or instructions shown; consult the linked blank form and official instructions when preparing your own document.
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Educational Sample – Federal Tort Claim (SF-95 Format)
This educational template mirrors the structure of the U.S. Department of Justice Standard Form 95 (SF-95) for instructional purposes only. It is not an official government form. To file an actual claim, obtain the SF-95 directly from https://www.justice.gov/civil/standard-form-95.
Page 1 – Sample Claim Form
1. To: U.S. Department of Justice — Torts Branch, Civil Division, Washington DC 20530
2. Name of Claimant: Chris Magis Nero© / Private Attorney General / Fiduciary Trustee
3. Address: 7200 W. Picture Rocks Rd., Tucson, AZ 85743 Phone: 520-612-9797 Email: chrisnero9999@gmail.com
4. Date and Time of Incident: March 2025 – May 2025
5. Basis of Claim: Trespass and deprivation of rights under color of law; unlawful execution of writ on federally protected sacred burial land; violation of RLUIPA and constitutional due-process rights; fiduciary breach by officers acting in concert with Cynthia Kuhn, presumed judicial officer of Pima County Superior Court.
6. Government Employee(s) Involved: Cynthia Kuhn – Pima County Superior Court; other agents acting under Department of Justice oversight.
7. Property Damage: Burial-ground property and personal assets at 7200 W. Picture Rocks Rd., Tucson, AZ.
8. Personal Injury: Emotional distress, spiritual injury, and deprivation of protected rights.
9. Amount Claimed: Total: $100,000,000,000 (Property + Personal + General Damages)
10. Witnesses: See attached Evidentiary Logbook Template and Exhibits 1–20.
11. Remarks: Claimant incorporates by reference all UCC-1 Financing Statements, Risk Management claims, and federal affidavits on record with Treasury and DOJ.
12. Signature: __________________________ Chris Magis Nero© Date: ____________
13. Notary / Verification: __________________________ (Notary Public – Arizona)
Page 2 – Filing Guidance and Evidence Index
Mail this claim by Certified Mail with Return Receipt to the address of the relevant federal agency. For Department of Justice filings, use: Civil Division, Torts Branch U.S. Department of Justice P.O. Box 888 Benjamin Franklin Station Washington, D.C. 20044
Attach the following supporting evidence: • Verified Exhibits 1–20 from your Evidentiary Logbook • UCC-1 Financing Statements and Federal Liens • Affidavit(s) of Truth or Damage Statement • Proof of Property Ownership and Trust Documentation • Any prior correspondence or Risk Management responses
Witness and mailing certification lines: Witness 1: ________________________ Date: ___________ Witness 2: ________________________ Date: ___________ Certified Mail #: ___________________________ Date Sent: ___________________________ Date Received (Return Receipt): ___________________________