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Notice of Claim Against the City of Cudahy

  1. 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.
  2. Claimant's Information
  3. Be as specific as possible. Example: 5 feet east of west corner of Elmira Road and Peabody
  4. What amount of money are you seeking to recover?
  5. 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:
  6. 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.
  7. Person filing on behalf of claimant
  8. 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.
  9. Leave This Blank:

  10. This field is not part of the form submission.