Fillable CLAIM AGAINST THE CITY OF SAN DIMAS (For (City of San Dimas)

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CLAIM AGAINST THE CITY OF SAN DIMAS (For (City of San Dimas)

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The CLAIM AGAINST THE CITY OF SAN DIMAS (For (City of San Dimas) form is 2 pages long and contains:

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  • 3 check-boxes
  • 45 other fields

Country of origin: US
File type: PDF

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CLAIM AGAINST THE CITY OF SAN DIMAS
(For damages to Persons or Personal Property)
Received by _______ via US MAIL Inter-Office Mail Over the Counter
TO THE HONORABLE MAYOR & CITY COUNCIL, THE CITY OF SAN DIMAS, CALIFORNIA
The undersigned respectfully submits the following claim and information relative to damage to persona and/or
personal property:
1. Name of Claimant_________________________________________________________________________
a. Address of Claimant_______________________________________________________________________
b. Telephone Number (_____) ________________ c. Date of Birth___________________________________
d. Social Security No.________________________ e. Driver’s License_________________________________
2. Name, telephone and post office address to which claimant desires notices to be sent If
other than above:____________________________________________________________________________
___________________________________________________________________________________________
3. Occurrence or event from which the claim arises:
a. Date_______________________ b. Time_________ a.m./p.m.
c. Place (exact & specific location)______________________________________________________________
___________________________________________________________________________________________
d. How and under what circumstances did damage or injury occur? Specify the
particular occurrence, event, act or omission you claim caused the injury or damage
(Use additional paper if necessary)______________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
e. What particular action by the City, or its employees, caused the alleged damage or
injury? ____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
City Clerk Stamp
A claim must be filed with the City Clerk of the City of San Dimas within six (6) months after which the incident or
event occurred. Be sure your claim is against the City of San Dimas, not another public entity. Where space is
insufficient, please use additional paper and identify information by paragraph number. Completed claims must
be mailed or delivered to the City Clerk, the City of San Dimas, 245 E. Bonita Avenue, San Dimas, CA 91773-3002
4. Give a description of the injury, property damage or loss, so far as is known at the time of this claim. If there
were no injuries, state “no injuries”.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
5. Give the name(s) of the City employee(s) causing the damage or injury:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6. Name and address of any other person injured:
__________________________________________________________________________________________
__________________________________________________________________________________________
7. Name and address of the owner of any damaged property:
__________________________________________________________________________________________
__________________________________________________________________________________________
8. Damages claims:
a. Amount claimed as of this date: $_________________
b. Estimated amount of future costs: $_________________
c. Total amount claimed: $_________________
d. Basis for computation of amounts claimed (attach copies of all bills, invoices, estimates, etc.)
9. Names and addresses of all witnesses, hospitals, doctors, etc.
a.________________________________________________________________________________________
b.________________________________________________________________________________________
c.________________________________________________________________________________________
d.________________________________________________________________________________________
10. Any additional information that might be helpful in considering this claim:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (Penal C
ode
§72; Insurance Code §556.1)
I have read the matters and statements made in the above claim and I know the same to be true of my own
knowledge, except as to those matters stated upon information or belief as to such matters I believe the same to be
true. I certify under penalty of perjury that the foregoing is TRUE AND CORRECT.
Signed this ___________day of ________________________, 20___, at___________________________
______________________________________
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CLAIM AGAINST THE CITY OF SAN DIMAS (For (City of San Dimas)

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Completed 16 July 2020

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