Official Federal Forms > US Department Of Justice > Civil Division
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 . |
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UNASSERTED CLAIMS AND ASSESSMENTS AGENCY/COMPONENT: _____________________ AGENCYS $$ MATERIALITY LEVEL FOR REPORTING: _____________________ (This is your agency threshold for materiality) 1. Name of Matter. (Include name by which the matter is commonly kno wn.) 2. Nature of the Matter. (Include a description of the matter .) 3. The Governments Planned Response( if the claim is asserted) . 4. An Evaluation of the likelihood of 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.) 5. An Estimate of the Amount or Range of Potential Loss (if one can be made, for losses considered to be probable or reasonably possible). 6. The Name and Phone Number of the Agency and DOJ Attorneys Handling the Case( and any outside legal counsel/other lawyers reespenting orr advising the government in the matter). 7. The Sequence Number (based on the total number of Unasserted Claims and Assessments your agency/component is submitting. e.g. Number ___ of ____ ). ( #) (to t al ) Attorney-Client Agency Work Product Privilege
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