Please read the INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator.

Section X, items
MOTOR VEHICLE
Privacy Act 73 thru 83c are filled out by the operator's supervisor. Section XI thru XIII are filled out by an
ACCIDENT REPORT
Statement on Page 3 accident investigator for bodily injury, fatality, and/or damage exceeding $500.
SECTION I - FEDERAL VEHICLE DATA
1. DRIVER'S NAME (Last, First, Middle) 2. DRIVER'S LICENSE NO./STATE/LIMITATIONS 3. DATE OF ACCIDENT

4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS 4b. WORK TELEPHONE NUMBER

5. TAG OR IDENTIFICATION NUMBER 6. EST. REPAIR COST 7. YEAR OF VEHICLE 8. MAKE 9. MODEL 10. SEAT BELTS USED?
$ YES NO
11. DESCRIBE VEHICLE DAMAGE

SECTION II - OTHER VEHICLE DATA (Use Section VIII if additional space is needed)
12. DRIVER'S NAME (Last, First, Middle) 13. SOCIAL SECURITY NO./ 14. DRIVER'S LICENSE NO./STATE/LIMITATIONS
TAX IDENTIFICATION NO.

15a. DRIVER'S WORK ADDRESS 15b. WORK TELEPHONE NUMBER

16a. DRIVER'S HOME ADDRESS 16b. HOME TELEPHONE NUMBER

17. DESCRIPTION OF VEHICLE DAMAGE 18. ESTIMATED REPAIR COST

$
19. YEAR OF VEHICLE 20. MAKE OF VEHICLE 21. MODEL OF VEHICLE 22. TAG NUMBER AND STATE

23a. DRIVER'S INSURANCE COMPANY NAME AND ADDRESS 23b. POLICY NUMBER

23c. TELEPHONE NUMBER

24. VEHICLE IS 25a. OWNER'S NAME(S) (Last, First, Middle) 25b. TELEPHONE NUMBER
CO-OWNED RENTAL
LEASED PRIVATELY OWNED
26. OWNER'S ADDRESS(ES)

SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed)
27. NAME (Last, First, Middle) 28. SEX 29. DATE OF BIRTH

30. ADDRESS

A 31. MARK "X" IN TWO APPROPRIATE BOXES 32. IN WHICH VEHICLE 33. LOCATION IN VEHICLE 34. FIRST AID GIVEN BY
KILLED DRIVER PASSENGER FED

INJURED HELPER PEDESTRIAN OTHER (2)

35. TRANSPORTED BY 36. TRANSPORTED TO

37. NAME (Last, First, Middle) 38. SEX 39. DATE OF BIRTH

40. ADDRESS

B 41. MARK "X" IN TWO APPROPRIATE BOXES 42. IN WHICH VEHICLE 43. LOCATION IN VEHICLE 44. FIRST AID GIVEN BY
KILLED DRIVER PASSENGER FED
INJURED HELPER PEDESTRIAN OTHER (2)

45. TRANSPORTED BY 46. TRANSPORTED TO

a. NAME OF STREET OR HIGHWAY b. DIRECTION OF PEDESTRIAN (SW corner to NW corner, etc.)

FROM TO
47.
Pedestrian 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 STANDARD FORM 91 2/2004

Previous editions are not usable Prescribed by GSA-FMR 102-34.290
 SECTION IV - ACCIDENT TIME AND LOCATION (Use Section VII if additional space is needed)
48. DATE OF ACCIDENT 49. PLACE OF ACCIDENT (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection; Kind of locality (industrial, business,
residential, open country, etc.); Road description).

50. TIME OF ACCIDENT

AM
PM
51. INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED 52. POINT OF IMPACT
(Check one for each
vehicle)

FED 2 AREA

a. Front
b. Right Front
c. Left Front
d. Rear
e. Right Rear
f. Left Rear
g. Right Side
h. Left Side
53. DESCRIBE WHAT HAPPENED (Refer to vehicles as "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of vehicles, road conditions,
weather conditions, driver visibility, condition of accident vehicles, traffic controls (warning light, stop signal, etc.), condition of light (daylight, dusk, night, dawn, artificial light,
etc.), and driver actions (making a U-turn, passing, stopped in traffic, etc.).

SECTION V - WITNESS/PASSENGER (Witness must fill out SF 94, Statement of Witness) (Continue in Section VIII.)
54. NAME (Last, First, Middle) 55. WORK TELEPHONE NUMBER 56. HOME TELEPHONE NUMBER

A 57. WORK ADDRESS 58. HOME ADDRESS

59. NAME (Last, first, middle) 60. WORK TELEPHONE NUMBER 61. HOME TELEPHONE NUMBER

B 62. WORK ADDRESS 63. HOME ADDRESS

SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)

64a. NAME OF OWNER (Last, first, middle) 64b. WORK TELEPHONE NUMBER 64c. HOME TELEPHONE NUMBER

64d. WORK ADDRESS 64e. HOME ADDRESS

65a. NAME OF INSURANCE COMPANY 65b. TELEPHONE NUMBER 65c. POLICY NUMBER

66. ITEM DAMAGED 67. LOCATION OF DAMAGED ITEM 68. ESTIMATED COST

SECTION VII - POLICE INFORMATION

69a. NAME OF POLICE OFFICER 69b. BADGE NUMBER 69c. TELEPHONE NUMBER

70. PRECINCT OR HEADQUARTERS 71a. PERSON CHARGED WITH ACCIDENT 71b. VIOLATION(S)

STANDARD FORM 91 2/2004 PAGE 2

 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. Section 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 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 the 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.
SECTION IX - FEDERAL DRIVER CERTIFICATION
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. DESTINATION

75. EXACT PURPOSE OF TRIP

DATE TIME (Include AM or PM) DATE TIME (Include AM or PM)

77. ACCIDENT
76. TRIP BEGAN
OCCURRED
78. AUTHOURITY FOR THE TRIP WAS GIVEN TO THE OPERATOR 79. WAS THERE ANY DEVIATION FROM DIRECT ROUTE?

ORALLY IN WRITING (Explain) NO YES (Explain)

80. WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS? 81. DID THE OPERATOR, WHILE ENROUTE, ENGAGE IN ANY ACTIVITY OTHER
THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED?
YES NO (Explain) NO YES (Explain)

a. DID THIS ACCIDENT OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY?

82. COMPLETED b. COMMENTS
BY DRIVER'S YES
SUPERVISOR NO

83a. NAME AND TITLE OF SUPERVISOR 83b. SUPERVISOR'S SIGNATURE AND DATE 83c. TELEPHONE NUMBER

STANDARD FORM 91 2/2004 PAGE 3

 SECTION XI - ACCIDENT INVESTIGATION DATA
84. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION? NO YES (If checked, explain below.)

85. PERSONS INTERVIEWED

NAME DATE NAME DATE
a. c.

b. d.
86. ADDITIONAL COMMENTS (Indicate section and item number of each comment)

SECTION XII - ATTACHMENTS

87. LIST ALL ATTACHMENTS TO THIS REPORT

SECTION XIII - COMMENTS/APPROVALS

88. REVIEWING OFFICIAL'S COMMENTS

89. ACCIDENT INVESTIGATOR 90. ACCIDENT REVIEWING OFFICIAL

a. SIGNATURE b. DATE a. SIGNATURE b. DATE

c. NAME (First, Middle, Last) c. NAME (First, Middle, Last)

d. TITLE d. TITLE

e. OFFICE e. OFFICE

f. OFFICE TELEPHONE NUMBER f. OFFICE TELEPHONE NUMBER

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

STANDARD FORM 91 2/2004 PAGE 4