Attachment 20-Witness Statement SF94-20b.pdf

5. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?

STATEMENT OF WITNESS

(Attach additional sheets if necessary)

Please read the Privacy Act Statement on Page 3

OMB Control Number: 3090-0118 Expiration Date: 1/31/2027

STANDARD FORM 94 (REV. 11/2020)

Prescribed by GSA - FMR (41 CFR) 102-34

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0118. We estimate that it will take 20 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (MVCB), 1800 F Street, NW, Washington, DC 20405.

c. E-MAIL ADDRESS

b. HOME ADDRESS (Include ZIP Code)

a. NAME OF WITNESS:

1. WITNESS INFORMATION

f. HOME TELEPHONE NUMBER e. CELLULAR TELEPHONE NUMBER d. WORK TELEPHONE NUMBER p.m.

a.m. d. TIME YOU ARRIVED AT SCENE?a. DID YOU WITNESS THE ACCIDENT?

2. ACCIDENT INFORMATION

6. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY.

4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED.

3. WHERE DID THE ACCIDENT OCCUR? (Give Street Location, City, and State)

9. DID YOU NOTICE ANYTHING UNUSUAL PRIOR TO OR DURING THE ACCIDENT?

IF YES, PLEASE DESCRIBE WHAT YOU NOTICED AND WHY YOU THINK IT WAS PERTINENT TO THIS ACCIDENT.

8. DESCRIBE ROAD AND CONDITIONS THAT INFLUENCED THE ACCIDENT (e.g. weather, terrain, debris, road work, time of day).

7. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY.

b. DATE OF ACCIDENT: c. TIME OF ACCIDENT:

p.m.

a.m.

1. Number the vehicles involved as follows:

Government Vehicle (GOV) #1 - Private Vehicle (POV) #2 - Additional Vehicles GOV or POV as #3, etc. and show direction of travel by arrow.

(Example: ----> <----)

2. Use solid line to show path before accident Broken line after accident - - - - - - - - -

3. Show pedestrian by ------------------------>

4. Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|

5. Give names or numbers of streets or highways

6. Indicate north by arrow in this compass

STANDARD FORM 94 (REV. 11/2020) PAGE 2

10. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED.

1 2

TIME:DATE: 13. WITNESS SIGNATURE:

12. WITNESS NAME:

NOTES: Include other pertinent information such as: How many drivers/vehicles were involved? Describe the vehicles. How many passengers per vehicle(s)?

Were Police, Fire and/or Rescue on the scene? Was a Police Report completed? Were Police, Fire and/or Rescue present before or after you arrived on the scene? Describe the accident (provide your detailed account).

The information on this form is subject to the Privacy Act of 1974 - United States Code set forth at 5 U.S.C. § 552a. Authority to collect the information is set forth at 40 U.S.C. § 491 and 31 U.S.C. § 7701. The information 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 Government Accountability 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 the Treasury and the Department of 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.

STANDARD FORM 94 (REV. 11/2020) PAGE 3

PRIVACY ACT STATEMENT

5. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?

STATEMENT OF WITNESS

(Attach additional sheets if necessary) Please read the Privacy Act Statement on Page 3 OMB Control Number: 3090-0118 Expiration Date: 1/31/2027

STANDARD FORM 94 (REV. 11/2020)

Prescribed by GSA - FMR (41 CFR) 102-34 Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0118. We estimate that it will take 20 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (MVCB), 1800 F Street, NW, Washington, DC 20405.

c. E-MAIL ADDRESS

b. HOME ADDRESS (Include ZIP Code)

a. NAME OF WITNESS:

1. WITNESS INFORMATION

f. HOME TELEPHONE NUMBER

e. CELLULAR TELEPHONE NUMBER

d. WORK TELEPHONE NUMBER p.m.

a.m.

d. TIME YOU ARRIVED AT SCENE?

a. DID YOU WITNESS THE ACCIDENT?

2. ACCIDENT INFORMATION

6. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY.

4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED.

3. WHERE DID THE ACCIDENT OCCUR? (Give Street Location, City, and State)

9. DID YOU NOTICE ANYTHING UNUSUAL PRIOR TO OR DURING THE ACCIDENT?

IF YES, PLEASE DESCRIBE WHAT YOU NOTICED AND WHY YOU THINK IT WAS PERTINENT TO THIS ACCIDENT.

8. DESCRIBE ROAD AND CONDITIONS THAT INFLUENCED THE ACCIDENT (e.g. weather, terrain, debris, road work, time of day).

7. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY.

b. DATE OF ACCIDENT:

c. TIME OF ACCIDENT:

p.m.

a.m.

1. Number the vehicles involved as follows:

Government Vehicle (GOV) #1 - Private Vehicle (POV) #2 - Additional Vehicles GOV or POV as #3, etc. and show direction of travel by arrow.

(Example: ----> <----)

2. Use solid line to show path before accident Broken line after accident - - - - - - - - -

3. Show pedestrian by ------------------------>

4. Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|

5. Give names or numbers of streets or highways

6. Indicate north by arrow in this compass

STANDARD FORM 94 (REV. 11/2020) PAGE 2

10. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED.

10. Indicate on the diagrams below what happened. This diagram consists of a 4 way intersection with traffic lights on each side. Each side has 4 lanes separated by medians. 2 lanes going to the left, 2 lanes going up, 2 lanes going down, and 2 lanes going to the right.

.\Higway Diagram.PNG .\Straight Road.PNG

10. Indicate on the diagrams below what happened. This diagram consists of a straight road with 2 sets of 2 lanes side by side separated by a median in the middle.

..\Downloads\best-online-collection-of-free-to-use-clipart-contact-us-privacy-Yb9pkD-clipart.jpg

10. Indicate on the diagrams below what happened. This diagram consists of a curved road with 2 lanes separated by a dashed dividing line.

.\Business Objects Forms\Diamond for SF 94.PNG Yellow diamond symbol used to represent pedestrians.

..\..\Business Objects Forms\Compass for SF 94.PNG Image of a compass with 4 directions (North, South, East and West) used to indicate North.

TIME:

DATE:

\\iaimain\apps1\Pam_Ward\Logos\Pointer.jpg Marker indicating where to sign the form (at Item 13, Witness Signature).

13. WITNESS SIGNATURE:

12. WITNESS NAME:

NOTES: Include other pertinent information such as: How many drivers/vehicles were involved? Describe the vehicles. How many passengers per vehicle(s)? Were Police, Fire and/or Rescue on the scene? Was a Police Report completed? Were Police, Fire and/or Rescue present before or after you arrived on the scene? Describe the accident (provide your detailed account).

The information on this form is subject to the Privacy Act of 1974 - United States Code set forth at 5 U.S.C. § 552a. Authority to collect the information is set forth at 40 U.S.C. § 491 and 31 U.S.C. § 7701. The information 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 Government Accountability 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 the Treasury and the Department of 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.

STANDARD FORM 94 (REV. 11/2020) PAGE 3

PRIVACY ACT STATEMENT

8.2.1.3144.1.471865.466429 Standard Form 94 - Statement of Witness