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2. Instructions
   Claims related to injury to person or damage to personal property must be presented to the City within six months from the date of loss. Claims related to any other loss must be presented not later than one year from the date of loss. Answer all items fully and to the best of your knowledge and information. Failure to do so may result in your claim being found insufficient.
4. Claimant's Information
6. Name
7. Phone
9. Mailing Address
11. City
12. State
13. Zip Code
15. Date & Time of Incident
    Date & Time of Incident

    Date & Time of Incident
17. Location of Incident
    Be as specific as possible. Example: 5 feet east of west corner of Elmira Road and Peabody
19. Description of incident which caused you to make this claim:
21. What specific injury, damages or losses were incurred?
23. What amount of money are you seeking to recover?

    1. The amount claimed totals less than $10,000.
    2. The amount claimed is more than $10,000 but not over $25,000; jurisdiction rests in Municipal Court.
    3. The amount claimed is more than $25,000 ; jurisdiction rests in Superior Court.
25. Enter the amount claimed:
27. How was this amount calculated? (Itemize and attach bills, repair estimates, receipts, etc.; if claim is for vehicle damage, obtain and attach two repair estimates):
29. What is your basis for claiming that the City or City employee(s) are the cause of your injury, damages or loss?
31. What are the name(s) of the City employee(s) whom you allege caused your injury, damages or loss, if known?
33. Name, address and phone number of any witnesses who can substantiate your claim:
35. Any additional information that you believe might be helpful to the City in considering this claim:
37. All notices and communications with regard to this claim will be directed to the Claimant shown on lines 1 and 2 above unless you complete the following to identify to whom further communication should be directed:
39. Name
40. Relationship
42. Address
44. City
45. State
46. Zip Code
48. Phone
50. I/We, the undersigned, declare under penalty of perjury that I/we have read the foregoing claim for damages and know the contents thereof; that the same is true of my/our own knowledge and belief, save and except as to those matters wherein stated on information and belief, and as to them, I/we believe to be true.
52. Claimant eSignature
53. Date
    Date
55. eSignature
    Person filing on behalf of claimant
56. Date
    Date
58. Warning
    Presentation for allowance or payment of a false or fraudulent claim, with intent to defraud, is a crime punishable as a felony under California Penal Code, Section 72, and Insurance Code, Section 1871.1.
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

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