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Unasserted Claims And Assessments - Official Federal Forms

Unasserted Claims And Assessments Form. This is a national form and can be used in Civil Division US Department Of Justice .
 Fillable pdf Last Modified 3/27/2014
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UNASSERTED CLAIMS AND ASSESSMENTS AGENCY/COMPONENT: AGENCY'S MATERIALITY LEVEL FOR REPORTING: (This is your agency threshold for materiality.) 1. Name of Matter. (Include name by which the matter is commonly known.) 2. Nature of Matter. (Include a description of the matter. Also, if known, please indicate if this case is reimbursable to the Judgment Fund (i.e., Contract Disputes Act case or No FEAR Act case.) ) DOJ Attorney Comments 3. The Government's Planned Response. (If the claim is asserted.) DOJ Attorney Comments 4. An Evaluation of the Likelihood of an Unfavorable Outcome. (Choose one.) PROBABLE (An unfavorable outcome is likely to occur.) REASONABLY POSSIBLE (The chance of an unfavorable outcome is less than probable, but more than remote.) DOJ Attorney Comments 5. An Estimate of the Amount or Range of Potential Loss. (For probable and reasonably possible complete one.) Estimated amount of potential loss: Estimated range of potential loss: Estimated amount or range of potential loss is unknown: DOJ Attorney Comments 6. The Name and Phone Number of the Agency and DOJ Attorneys Handling the Case. (Include any outside legal counsel/other lawyers representing or advising the government in the matter.) $ $ -$ DOJ Attorney Comments 7. The Sequence Number. (Based on the total number of pending or threatened Number cases your agency/component is submitting.) # of total Attorney-Client Agency Work Product Privilege Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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