Items 1 to 6: claimant
Name of claimant, area code, phone number and extension, date of loss or damage, street address, city, state and ZIP code, service or staff office, and division or branch.
GSA2116
Employee Claim for Loss or Damage to Personal Property
- Agency
- GSA
- Revision
- Rev. 7/2002
- Fillable fields
- 53
- Pages
- 1
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 2116: Employee Claim for Loss of or Damage to Personal Property
GSA Form 2116, Employee Claim for Loss of or Damage to Personal Property, is a one-page GSA form. The footer reads GENERAL SERVICES ADMINISTRATION and GSA FORM 2116 (REV. 7/2002), Prescribed by ADM 6200.3B. GSA hosts it in its forms library; its page lists the authority or regulation as ADM 6200.3A.
The Privacy Act information says the information will be used for filing a claim for loss of or damage to employee personal property, and that its solicitation is authorized by the Federal Military Personnel and Civilian Claims Act of 1964, 31 U.S.C. §3701, et seq, as amended. The note at the top says to complete and submit the form, along with supporting documents, to the Regional Counsel's office for claims in excess of $2,500.
Items 1 to 13 cover the claimant, the loss or damage, an itemized property listing, insurance and the certification. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 2116
Items 7 and 8: location and amount
The location of the loss or damage and the total amount of the claim.
Item 9: description of property
An itemized listing with the date acquired, purchase price or value when acquired, value when lost or damaged, and estimated repair or replacement cost for each item.
Item 10: type of claim
Boxes for loss or damage and a brief statement of circumstances.
Item 11: insurance
Whether the property was insured. If yes, the name of the insurer and the amount collected, itemized.
Items 12 and 13: certification and signatures
The printed criminal and civil penalties, the claimant's certification, signature and date, then the signature, name, relationship and date of any other claimant.
How to complete GSA Form 2116
- 1
Fill in items 1 to 8
Enter the claimant's name, phone, date of loss or damage, address, office, division or branch, location and total amount of the claim.
- 2
List the property in item 9
Itemize each piece of property in columns (a) to (e). The form says to use an additional sheet, if necessary.
- 3
Describe what happened
In item 10, check loss or damage and write a brief statement of circumstances.
- 4
Report any insurance
In item 11, check yes or no. If yes, the form asks for the name of the insurer and the amount collected, itemized.
- 5
Sign the certification
The claimant signs and dates items 12a and 12b, certifying the claim is made with full knowledge of the penalties for wilfully making a false claim.
- 6
Submit with supporting documents
For claims in excess of $2,500, the form says to submit it, along with supporting documents, to the Regional Counsel's office.
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Submission, privacy and penalties
Where it goes
The note says claims in excess of $2,500 go to the Regional Counsel's office with supporting documents. The form prints no address and no routing for other claims.
Privacy
The form says disclosure is voluntary, and that failure to furnish the information will delay or prevent processing of the claim.
Criminal penalty printed on the form
Fine of not more than $10,000 or imprisonment for not more than 5 years or both (see 18 U.S.C. §§ 287, 1001).
Civil penalty printed on the form
The claimant shall forfeit and pay to the United States not less than $5,000 and not more than $10,000, plus not less than double the amount of damages which the Government sustained (see 31 U.S.C. § 3729).
Authority
The footer says Prescribed by ADM 6200.3B, while GSA's page lists ADM 6200.3A. The Privacy Act information cites 31 U.S.C. §3701, et seq.
Related forms
Who fills out GSA Form 2116?
The note, items and certification on the form name these.
Official sources and the blank
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Questions about Form GSA2116
Who issues GSA Form 2116?
The footer reads GENERAL SERVICES ADMINISTRATION and GSA FORM 2116 (REV. 7/2002), Prescribed by ADM 6200.3B. GSA hosts it in its forms library.
Where does GSA Form 2116 go?
The form says to complete and submit it, along with supporting documents, to the Regional Counsel's office for claims in excess of $2,500. It prints no address.
Is the information on GSA Form 2116 voluntary?
The Privacy Act information says disclosure is voluntary, and that failure to furnish the information will delay or prevent processing of the claim.
What if the property was insured?
Item 11 asks whether the property was insured. If yes, it asks for the name of the insurer and the amount collected, itemized.
Can someone else sign the claim?
Item 13 has blocks for the signature, name, relationship (if any) and date of an other claimant, who certifies on behalf of the claimant that the claim is made with full knowledge of the penalties.
What penalties does the form print?
A fine of not more than $10,000 or imprisonment for not more than 5 years or both, and a civil penalty of not less than $5,000 and not more than $10,000, plus not less than double the amount of damages which the Government sustained.
What law does the form cite?
The Federal Military Personnel and Civilian Claims Act of 1964, 31 U.S.C. §3701, et seq, as amended.